On
the incredible stage of the Teatro Olimpico, 78 physicians read aloud the
Hippocrates Oath: 78 new physicians, 50 women and 28 men.
For the third year in a row, the new women-doctors definitely outclass the
men. No, please do not think I am a male chauvinist. I am not and I have never
been. But one thing I am sure of: today,
the medical profession is no longer attractive for men as it used to be twenty
years ago. Female prevalence has started, exactly as it had in the schools.
Until yesterday, the few existing women doctors could be found in very specific
sectors: paediatrics, laboratories, morbid anatomy, hygiene and anaesthesia.
Today, the female presence has fairly broadened in internal medicine fields
(general medicine and geriatrics), in the infective and diagnostic sectors
(radiology and nuclear medicine), in the emergency facilities (first aid and
haemodialysis), as well as in operating rooms. Yes, also in the uncontested
kingdom of men! This is again a sign of the times.
And this is another fact on which healthcare reorganisation will have to be
based. Indeed, very often family responsibilities clash with the hospital
routine, which provides for night duties, immediate availability, working
on midweek holidays, urgency and emergency. Medicine is changing, but only
a few realise. This is why I would like to calmly share with the reader a
few thoughts on physicians and medicine today. Some have stated that disease
is a language: providing for words, as well as syntactic and grammatical rules.
Disease involves that a balance has been disrupted: the balance of one’s health
condition. It can express itself through multiple signs: fever, pain, rhythm
disorders, urine aspect, restlessness, mobility and speech disorders, personality
and coenaesthesia problems. This list could go on for ever, just as the Harrison.
Such signs can be objective, that is detectable by the doctor, or subjective,
in which case it is the patient who notices them.
The physician is the only person who can interpret them and rationally take
stock of them for a diagnosis to be reached. This is called semeiotics, and
is a crucial branch of holistic medicine, whereas it has become a forlorn
and obsolete specialisation in today’s technocratic and frantic medicine.
The disease is there to warn the patient that problems exist. The signs or
symptoms are more or less accurately interpreted by the patient, and related
to the doctor who — in turn – can evoke them and systematise them. Body language
becomes the patient’s and the doctor’s language.
The patient’s language is not always accurate and complete; the doctor’s language
is not always exhaustive and appropriate. Centuries and decades have changed
the roles in medicine.
The sick have changed from their position as passive subjects in the hands
of medicine men into active subjects, who want to know everything and participate.
Know everything? Sometimes. Participate? Always. Because if they cannot participate
they will expose. And what about physicians? From medicine men they have gradually
retrained as barons with their tail of attendants, and then as National Health
doctors and manager-physicians. But as medicine has modernised, physicians
have gradually lost the essence of their profession: they have lost their
role as confessors for the body and the person as a whole, to listen to the
patients’ symptoms and mind. Holistic medicine, where have you gone? Medical
science is an atypical science because it is not very scientific. It is not
an exact science, such as physics or mathematics, because it leads to few
certainties and many doubts and anxieties. It is doubt that generates syndromes.
It is doubt that generates so many hypotheses and differing diagnoses. It
is doubt that leads to defensive medicine.
Probabilities rather than certainties: risks rather than solutions. Modern
medicine can be summarised in the short history of rare diseases: there were
about a hundred during the ‘60s, whereas toady there are over five thousand,
and according to forecasts they will become dozens of thousands over the next
few decades, owing to the genetic boom. Every man to “his disease”. Is this
what medicine is meant to become? New diagnoses for new diseases for new people.
The medical language needs to be adjusted to new realities, in order to explain
to people that, in medicine, exception is becoming the rule, the diseases
are changing: we no longer seem to come across the acute glomerulonephritis
cases that existed thirty years ago! Clinic truth is difficult to achieve
and it often is not unequivocal. Medicine man, healer, baron, scientist, friend
and priest: this is what a good physician should be. Doubtful, reassuring,
updated and determined. Again, a good doctor should posses all these features.
A compassionate doctor is not a good professional. A physician with self-provided
references is a dangerous physician.
Being
a Physician Today
The medical profession is a peculiar one. Knowledge without humanity generates
monsters. Humanity without knowledge causes damage. Medicine requires the
availability of inductive and deductive mechanisms, a tangible bent for analysis
and synthesis. Forty years ago the university course in Medicine was only
open to Classic and Scientific ‘Liceo’ diploma holders, because in those days
liceos taught the basics of logic reasoning.
Latin, Greek, Mathematics and Physics forced people to make daily use of logic,
in every possible shape and form. The opening of the Faculty of Medicine also
to technical school diploma holders has had a strong impact on the profession,
because it has churned out thousands of medical graduates wanting in analytic-synthetic
skills and in a good command of logic processes. Some of these have learnt
logic mechanisms in the field, after years of experience, whereas all those
who have not succeeded in this personal achievement, have become mediocre
professionals and technocrats. It is true.
One does not need to be a genius to become a good doctor. It is however indispensable
to be humble: not to be ashamed to ask for the assistance of more knowledgeable
professionals, assimilate the clinic course of more talented Colleagues, face
each other rather than avoiding comparisons, read and study rather than resting
on acquired knowledge. A physician’s work can be summarised in a few distinct
activities.
Not simply doing and deciding (A. Tramarin, 2002), but also knowing, deciding
and doing. Knowledge reduces the possibilities of making mistakes and makes
the decision-making process easier. If correct decisions are made, it is possible
to do (if one is able to do!) or arrange for others to do. Making decisions
means having available both the means (medical culture) and the method (from
signs to a diagnosis). It means doing the right thing in the right way, which
is not easy.
Today, however, we have reached the point of “being able to do the right thing
in the best possible way”. And this is quite a different thing, because “neutral”
medical performance is influenced by healthcare economics and business-management
type aspects. The high mortality rate associated with cases of acute renal
failure has only one cause: dialytic treatment is performed (everywhere) when
possible and as long as possible, and not when it has to be done and for the
amount of time that it has to be done. This is but one example, but it speaks
volumes.
No Healthcare Enterprise (ASL) can afford today a team that is exclusively
assigned to acute dialytic emergencies and acute replacement therapies! This
problem has to do with healthcare economics, which has nothing to do with
“do it right, right” situations. Doctors’ working conditions are almost never
the ideal ones required to “be able to decide” and to “be able to do” (A.
Tramarin, 2002). How many times, under similar circumstances, have we blamed
the uncontrollable wastes of administrative bureaucracy, which deprives “pure”
medical performance of its resources!
The writer is well aware of the essentiality and efficiency of the RAMBAM
Hospital (Haifa) which however, pursuant to the Legislative Decree 626/94,
should be closed, had it been in Italy!
Diseases and Patients
There are many ways of being a doctor: by assisting the patient or working
on the disease; by fighting in the trenches (ward or surgery) or working behind
the lines of the company’s organisation (in medical management, assessment
units and committees); by providing assistance or carrying out research work,
or doing a bit of each; by combining the profession with trade union activity
or politics; by acting for personal ambition or for the common “good”.
Being a physician, however, is a total commitment. This is something our wives
know very well, since they often regard themselves as “widows in white” (translator’s
note:a double play on words in Italian, since widows traditionally wear black,
and “white widow” is the Italian expression for “grass widow”). Anyway the
basic underlying factor is a man and his humanity. Humanity and not personality,
because one can also be a personality without being human. Humanitas: to take
it upon oneself to help others. This is a free, not a literal translation,
as it instantly conveys the feeling of allowing the other person to flow in
with his problems, the idea of sharing. I reject the concept that there may
be a “religious” medicine and a “lay” medicine. There is only one medicine;
and it is up to its actors to interpret it with humanity, without adding any
specific attributes. I know that many will not like this.
But this is Jesus’ teaching: “A certain man went down from Jerusalem to Jericho
…” And the man did not worry about the wounded man’s race or religion. He
spared no expenses. He showed humanity for a person who was weak, vulnerable
and alone, without hesitation. I do not accept the idea that “the art of kindness
and generosity” is religious and that “technocratic medicine” is lay.
Being lay is not an offence. Being religious is not a merit. What count are
the feelings with which the medical art is practised, whether the person is
a Catholic or a Muslim, a Christian or a Jew, or a Gnostic. It is important
to be, not to appear; to offer the patient substance and not just appearances.
Health
and Economics
How many have realised it? As of today, the constitutional right to health
is no longer an absolute right, but a conditional right, the conditions being
the availability of money and the annual financial plans, whether national
or regional.The State-Region treaty of 8 August 2002 set the economic rules
which are to govern healthcare over the 2002-2004 period: it will not be possible
to spend more than 5.88% of the Gross Domestic Product (GDP). Hence the frantic
search for systems designed to save on resources; the LEA (which stands for
Essential Levels of Assistance, and means in fact healthcare curtailing),
the reduction in beds for acute cases, the simplification (hence reduction)
of the therapeutic manual, the priority given to daily activities (D.H. and
O.S.) irrespective of the type of patient involved and of his degree of autonomy.
Budget restrictions and the management setup (unique of its kind worldwide),
called directional monocracy, have overturned the healthcare hierarchies and
disrupted their values. Over the last few decades we have therefore switched
from the “patient” value criterion to the “disease” value criterion and lastly
to the “cost/disease” value criterion. A backward cultural revolution which
was accompanied, to start with, by an excessive trust in the technocracy of
diagnostics, and subsequently by an increasingly deep professional discomfort.
The conversion of Health Units into business units (“aziendalizzazione” process)
is not a value; the DRG (Diagnosis Related Groups) factor is not a value;
the LEA levels are not values. Professional ethics is a value. The ethical
nature of medicine is a value. Resource optimisation is an aim, a method,
a technique, but not a value. Efficiency does not guarantee equity, because,
when it is limited by financial considerations, it ends up by grading pathologies,
or rather patients. Expense reduction is a must. However, economics cannot
impose restrictions on the ethical nature of medical performance. The relationship
between money and health is certainly a controversial point. For centuries
physicians have worked without taking into account the costs involved by their
work. But today, the exceeding care for budgets and balances has resulted
in huge healthcare injustice, not only in the USA but also in Italy. Health
related travel is one aspect, as well as the boom of alternative medicine
and of private healthcare expense.
The National Health Service is going backwards. The technocrat physician devotes
little time to people. Holistic medicine is being punished. Hence the huge
demand for any non-western medicine that devotes more care to people than
to diseases. Well, here is where we need to start again from.
From medical performance viewed as “confession”. As unconditional care for
the problems of the person who approaches me asking for help. Complete medical
assistance: anamnesis, physical examination, tests, diagnosis and therapy.
Medical service out of space and time. Again today as yesterday. Today more
than yesterday. Let us recall the district doctor and his “mission”. Let us
recall the hospital doctor and his role: towards the patient and towards society.
Let us think about that today. In a dawning society that is growing old with
few values and few certainties.
(trasl.Interpres)
Stefano Biasioli
CIMO
