The paradoxes of contemporary medicine

POINT OF VIEW

The paradoxes of contemporary medicine

Wilson Luiz sanvito^I; Zied Rasslan^II

^ITenured and Full Professor in Neurology, Faculdade de Ciências Médicas da Santa Casa de São Paulo, São Paulo, SP, Brazil

^IIAssistant Professor; PhD, Department of Internal Medicine at Faculdade de Ciências Médicas da Santa Casa de São Paulo and Physician at Unidade de Primeiro Atendimento in Hospital Israelita Albert Einstein, São Paulo, SP, Brazil

^{Correspondence to}

The last 60 years have witnessed dramatic changes in all spheres of human activity. We live in the age of impermanency, in which scientific and technological advances happen with astonishing speed, and cause such an impact on social phenomena that many times chaotic or even conflicting situations are generated in human relationship. The euphoria in the face of material progress makes people bow down to machinery, in a fetishist attitude of mere worshipers of material idols. Individual's thoughts are chiefly turned to objects, not to the human being. The media revolution, through its main tool of manipulation, causes common citizens to act as mere robots.

The media effectively and constantly bombards us with news of prodigious medical advances, creating a new mythology: the disease under control. Contemporary medicine, marked by the industrial and medical complex (medical equipment and pharmaceutical industries) and anchored in molecular biology, has been increasingly advancing in all fields. Medical technology has made humans transparent, by providing better information and f images of their inside; it has also allowed us to see humans "turned inside out" through endoscopic procedures with microcameras. Simple diagnostic techniques in the past have become ever more therapeutic procedures (interventionist radiology, laparoscopic surgeries, placement of endovascular prostheses, etc). This exponential technological advance has caused a frisson not only in the medical field, but also in society; "scientific scatology" has prevailed.

Conversely, there is a significant discontinuity between medical advances and quality health care. There is a gap between "scientific medicine" and patients' needs. Another bias in contemporary medicine is the medical model adopted by "official medicine". The model is essentially biological (or biocentric), and the human body is considered to be a machine that can be analyzed in its different pieces; disease is treated as a malfunction of biological mechanisms.

In a general way this model (prioritized in medical schools) adopts the following configuration: 1) the patient as an object, 2) the physician as a mechanic, 3) the disease as a damage, 4) the hospital as a repair shop. However, it is important to understand that humans get sick from their biological, psychological, social, cultural, and environmental conditions. This biological model, supported by technology, has overspecialized medical practice and segmented it into different fields. The exaltation of scientific explanation and technical advances has determined the fragmentation of knowledge. Such such knowledge atomization has made the general practitioner insecure, and at many times a mere screener of cases for specialists. In his turn, the specialist only takes the responsibility for the "sick organ" in his field. It is as if the patient were "his/her stomach" or "his/her lungs" or something like that. For this reason, one physician leads to another physician. The consultation with different physicians corrupts the doctor-patient interaction, and as a result we have a case of the "anonymity plot". Golden rule: the patient needs to know his physician's name, both in public and private healthcare. The physician must be his/her reference.

There is, in fact, increasing deterioration of hands-on medicine (anamnese/physical examination) and overvaluation of complementary diagnosis exams and technical medical acts. Thus, the current scenario is of a medicine of specialized opinions and of hospital-centered nature. This model, in addition to increasing the costs, has low efficiency for a comprehensive health system. Said the American physician Alvan Feinstein: "The anamnese, the most sophisticated procedure of medicine, is an extraordinary investigation technique; in very few other ways of scientific research the investigated object speaks".

Conversely, the patient must be the center of system, not the disease. It is usually said that a good observer sees far the forest, the trees, and the leaves. The gateway to the healthcare system must not be the hospital, (except in emergencies), and the general practitioner should be the point of reference for the first medical attendance. This, unfortunately, is an endangered species.

In any case, we live in a privileged age, as we have a science that replaces a sick organ with a healthy one; that manipulates genes, allowing us to be hopeful for a vaccine against cancer and AIDS in the near future; that greets us with the prospect of the early days of a regenerative medicine for tissues with the management of stem cells. Ultrasonic scalpel, gene therapy, artificial prostheses implant, predictive diagnostic procedures, smart drugs... What is the next step of medicine? Surely, in terms of technological advances it is going well, but a triumphalist speech can only be justified when this excellence reaches the entire population. In the assistance services, some people are also asking themselves whether we are truly bound to a system of antimedicine. Is this the transitional chaos towards a new medicine for the patient? We really do not know! According to the deliciously ironic words of a false Chinese proverb: "It is extremely difficult to predict, especially regarding the future". It is possible to even observe a gap as to the relationship between general practitioner and specialists. As Franck-Brentano said, the medical staff is becoming a huge Tower of Babel, in which each specialist speaks his/her own language, a little bit hermetic to his colleagues. In order to oppose to this babelization and promote a better relationship among physicians from different fields, general meetings at the hospitals, besides continued medical education for general practitioners, would be recommendable. The gateway to the healthcare system (public or private healthcare) should be opened by well-qualified general physicians (practitioners, gynecologists, pediatricians, surgeons). They should be the jacks of all trades in the healthcare system and thus, apt to deal with sinusitis, primary cephalea, superficial mycosis, or community-acquired pneumonia... with no need to refer to specialists. Advances in medicine are not followed by physicians' increase of satisfaction. They are badly paid and in need of multiple jobs in order to survive, and working conditions are not always adequate. Besides, the physician and the patient who uses a medical institution or private health care system don't bond. Thus, the physician-patient-family interaction, which is supposed to pacify and relieve the pain, fear, suffering, and apprehension, is destroyed. What technological resource can replace this human aspect in medicine? The elements contained in such an interaction cannot be replaced by any medical technology, since they are exclusive virtues of human beings.

In Brazil, the Unified Healthcare System (Sistema Único de Saúde - SUS) presents low efficiency due to fraud, waste, an inadequate management model, and infrastructure problems such as the concentration of medical attendance at hospitals in medium and large urban centers. The hospital-centered model increases the cost per patient, since almost all medical attendance becomes complex in the end. Additionally, the medical attendance has poor quality. It is necessary to change priorities, emphasizing primary care in a well-managed network. "The public sector needs to adopt this model since, with good management; it will be possible to solve over 80% of health problems in the population. It must incentivize communitarian medicine practice, and strongly focusing on preventive medicine (vaccination, basic sanitation etc.), and mobilize human and financial resources to control endemic diseases. It is important to implement, in the public healthcare system, a medical career with defined promotion criteria based on productivity and meritocracy, and not only on the length of service. Physicians must be better paid in order to end the need for multiple jobs, which leads them to exhaustion and consequently lowers the quality of care. The prevailing model penalizes patients and physicians.

We are regrettably observing an increasing dehumanization of medicine. Evidently, many variable factors are involved in this phenomenon: mercantilization of medicine, high operational costs for medical care in a country with scarce resources, absence of an efficient public healthcare system, under-financing of public health, failure of universities in their mission of qualifying professionals in this field, low wages for health professionals, besides poor working conditions.

Changing this situation requires a set of measures that must be implemented in the health and education sectors. Without revolution in these fields, we unfortunately will not have a future as a major world power. It is really necessary to take action, as a Chinese proverb (this time a true one) says: "a journey of a thousand miles begins with the first step".

Study conducted at the Faculdade de Ciências Médicas da Santa Casa de São Paulo, São Paulo, SP, Brazil

Publication Dates

• Publication in this collection
  13 Dec 2012
• Date of issue
  Dec 2012