Rural Round-up: a rural practice in Southern Italy

An example of continuity of care across two generations of family doctors.

In this month's rural round-up, Dr Ferdinando Petrazzuoli describes his rural practice in Ruviano, Province of Caserta. Regione Campania in Southern Italy (Photo)

I am a middle aged Italian family doctor who lives and works in a rural village in Southern Italy. My rural home village is called Ruviano in the province of Caserta, Campania region. It has less than 2000 inhabitants, and is about a one hour drive from Naples. I work in a solo doctor practice and my surgery is in a wing of my own house. This is quite unusual and considered barely legal nowadays, but is tolerated as I started my practice long ago.

Living and working in the same building has its advantages and disadvantages. You save time and money but are on call all the time. My patient list consists of nearly 1500 patients. Over 35% of my patients are over the age of 65. (Children under six years are cared for by the local health district paediatrician.) Many patients are farmers.

Photo: My house - my practice is in the right side.
I have been working as a family doctor since 1989. To be honest this was not my initial choice but the result of the lack of prospects in another field: cardiology.

I have a diploma in cardiology and another in cardiac surgery and used to work at the University Department of Cardiology and Cardiac surgery of the University “Federico II” in Naples. Unfortunately in 1989 my father, who was also a family doctor in my home village, died so I decided to take over. It was not an easy decision for me at that time, but one I will never regret.

My patients know me not only as a doctor but as a person and I know most of my patients just as well. Usually I don’t have to ask for a family medical history - I already know their family medical history. Many of my patients used to be my father’s patients and some elderly people with early cognitive problems tend to get confused and speak to me as I were my father, often reminding me gratefully of the good old times when I saved their lives in the late fifties!!!

In Italy patients are free to access their family doctor whenever they require medical attention. In my area family doctors usually see patients without appointments.
Although this system has some advantages in terms of access, nothing can be done to stop patients from attending at all hours for minor diseases and the phenomenon of “frequent attenders” is widespread.

Family doctors also perform home visits as required. I perform at least 35 home visits per week, especially for patients who aren’t mobile. Most of the elderly remain in their own homes and their caregivers are often middle aged ladies coming from Eastern Europe.

Photo: My surgery

The family doctor service officially runs on a 12-hour basis, five days a week. Between 8pm and 8am on weekdays, and from Saturday 10am to Monday 8am patients are supposed to refer to an “on call service” but many rural patients rely heavily on their local GP. Emergencies are dealt with by an emergency system called 118 (actually 118 is the phone number of this service!)

Some of us are accredited for Vocational Training for GPs, and already teach medical students during their clinical GP attachments.

I usually deal with serious ailments and chronic diseases but my work is also bureaucratic: repeat prescriptions and transcriptions of specialists’ prescriptions, what feels like hundreds of certificates and so on, fortunately my secretary gives me a hand.

In Italy, continuity of care is provided through patient registration and most family doctors have electronic patient records. Private primary care is practically non-existent – especially in poor rural areas. Family doctors are paid according to a capitation system: they have a fixed list of patients and are paid according to the number and age of patients on that list.

Public secondary care usually works with an appointment system, but patients have to be referred by their own GP who holds a gate keeper role.

Secondary and tertiary care can be accessed through a completely private service that is expensive and not very popular or through two different types of public hospitals to which patients can be referred free of charge. These free services are provided in state owned and non-state-owned clinics and hospitals.

There are often long waiting lists for state owned centres but fortunately not for the non-state owned centres and most patients are referred into this part of the service.

This creates some ill-feeling from time to time. Health authorities are often complaining and accusing family doctors of being affected by some sort of illegal pressure from the non-state owned clinics!!

Map: where is Ruviano?

Primary care in Italy is well organised and it has succeeded in promoting and providing satisfactory preventive and curative health services. The basic health needs of my patients are met.

What is lacking is the provision of rehabilitation services. Domiciliary health services for the elderly and disabled people are almost non-existent except for some basic community nursing.

A weak point is that family doctors in Italy don’t have the rights and working conditions that most of our hospital colleagues have. For example, unlike them we have to pay for locums if we need to take sick leave, study leave or when we decide to go on holiday.

I enjoy being part of WONCA.

I started attending the WONCA Europe Conferences in 2001 in Tampere Finland, and since then I have never missed one. In 2002, I started attending the European General Practice Research Network (EGPRN) Conferences in Avignon, France, and in 2008, I became the Italian national representative of EGPRN. In 2010, I was elected as a member of the EGPRN executive board. Now I am still on the EGPRN executive board and I am the chair of the Education Committee.

I joined EURIPA, in 2006, and I have been involved in many initiatives, sometimes joint EGPRN-EURIPA activities, over the past five years. Recently I have been nominated as chair of the EURIPA research committee, a position that was held by the late and never forgotten Claudio Carosino.

That’s just a small insight into the working life and interests of an Italian rural family doctor.

If you would like to contact Ferdinando