Series: 'Medical desertification and care wandering' — Article 2/5
How does a “stable” patient become structurally invisible until acute decompensation? The answer lies in four perfectly aligned gears that turn abandonment into a statistical phenomenon, even among the most dedicated physicians. A mechanism that does not produce cynical doctors but a system that mechanically makes invisible those who need it most.
Against 12.2 million chronic patients growing at 2.8 % per year, GPs will lose 10 % of their workforce by 2030, with 47 % already over 55. New physicians legitimately no longer aspire to working 60-hour weeks in isolated areas. The quantitative pressure makes it mathematically impossible to maintain continuous follow-up for complex chronic patients.
Fee-for-service creates an hourly revenue ratio of 1:3 in favour of simple acts. Ski-trauma consultation: €25 for 15 minutes. Polypathological follow-up: €25 for 45 minutes plus coordination with six specialists. Supplementary payment mechanisms exist (GP Patient Roster Payment, ROSP) but remain marginal against the structural incentive of the simple act.
A physician following 250 polypathological patients must manage 3,750 vigilance points, 2,500 therapeutic lines, and 1,250 interprofessional relationships. Results, renewals, symptoms, interactions, screenings, prevention — the cognitive load is humanly impossible to absorb without tooling. This is not a problem of individual competence but of cognitive capacity facing the volume.
Actors work in watertight silos. The shared medical record remains underused, coordination is asynchronous via paper mail, fax or unsecured messaging. No orchestrator connects specialists, community care, hospital, nurses, or pharmacist. André becomes the sole interface between the actors of his own care pathway — a role beyond his capacity.
A properly followed chronic patient is seen 4 hours per year under current planned-maintenance standards. The remaining 8,756 hours constitute the blind zone where blood pressure drifts, creatinine rises, blood sugar escalates, fluid retention sets in, and adherence deteriorates. Without continuous monitoring, these weak signals are invisible. Desertification is not an accident — it is an emergent property of the system.
The problem is not quantitative but structural. Adding physicians does not fix an architecture defect. The question is not “how to do more?” but “how to do differently?”. Four gears, one outcome: the complex chronic patient is mechanically expelled from the follow-up radar. Not through malice, but by design. Article originally published on LinkedIn (in French).