Review of the book entitled O estudante de medicina e o paciente: uma aproximação à prática médica

BOOK REVIEW

Review of the book entitled O estudante de medicina e o paciente: uma aproximação à prática médica

Roosevelt M. S. Cassorla

Professor, Department of Medical Psychology and Psychiatry, Faculdade de Ciências Médicas, Universidade Estadual de Campinas (UNICAMP), Campinas, SP, Brazil. Member and training analyst of Sociedade Brasileira de Psicanálise de São Paulo, São Paulo, SP, Brazil.

^{Correspondence}

Alfredo Cataldo Neto, Ivan Antonello, Maria Helena Itaqui Lopes (orgs.)

Porto Alegre, EDIPUCRS, 2006, 219 p.

Due to a practice in which the medical professional tends to feel as only a piece of an inhuman machine, hostage of exhausting activities and likely to experience several forms of suffering, there is a lack of deep knowledge of the variables that interfere with such deterioration. This is probably the reason why, in our country, there have been studies and experiments that understand and help physicians to have a better knowledge of their work and of themselves.

This demand for understanding was initially focused on areas connected to planning of actions towards collective health, which have obtained relative success. Curiously, however, if we have a Brazilian Unified Health System that is theoretically almost perfect, it still has many flaws in practice. It is interesting to note that in this system physicians are often scapegoats, both for users and authorities, health plans and other members of health teams. Reactive attitudes, defensive or aggressive, taken by physicians and that are sometimes felt as being only corporative, contaminate the medical activity, which should be dedicated to the patient, by several types of conflicts.

During the 1960's-1980's, emphasis on social aspects of the disease used to hide and reveal a certain impotence over a wider action for the functioning of society as a whole. Concomitantly and subtly, in some medical schools a few professors did not abandon their ideals, often romantic, in favor of a "person's medicine" (in the words of a psychiatrist called Danilo Perestrello), in which the human being was seen not only as a disease or a sick system or organ. Nevertheless, its influence in medical teaching and practice was too small. This was a consequence of several factors. Among them, the fact that most of those physicians came from the fields of psychiatry and psychology, many presenting great difficulty in establishing a dialogue between their peers in other specialties. Even the traditional Balint groups, very useful instruments to understand the vicissitudes of the mental functioning of a physician-patient interaction, only reached a few physicians who were already predisposed to perceive emotional phenomena.

Over the past 20 years, development and idealization of technology applied to medicine and immoderate drug advertising have made the population and physicians believe that the power attributed to medicine with regard to diseases had exponentially increased. In fact, even if there had been some development, perception of patients (and physicians) as human beings has been reduced. They have become things among devices, examinations and procedures, without anyone asking them something about their humanity. Iatrogenic de-humanization has become part of an increasingly more expensive medicine, restricted to small groups of the population, concomitantly with a medicine for "poor people." This has made physicians into sophisticated technicians, who apply technology (in a certain medicine), or into unprepared technicians (in the medicine for poor people), to serve as a defense against social demands (violence, unemployment, poverty, anomia), disguised as health problems.

All those ailments, however, are not enough to avoid physicians from certainly being one of the most passionate professionals about their activity. This is a consequence of the fascination caused by medical school and later medical practice, which require total dedication from students in order to bear the responsibilities they aim and are imposed on them. Pleasure in helping another human being compensates their sacrifices. Several of such sacrifices could become unnecessary or be minimized if we had better working conditions.

But there are other factors, intrinsic to the medical activity, that students and physicians do not always know how to face. Among these factors is the contact with human limitations: reality of the disease, impossibility of always healing it, injustices that are part of life (since nature is unfair), reality of death. The extremely important fact that physicians deal with affections, feelings and emotions permeate all that, permanently invading patients, physicians and what happens between them. Physicians have the difficult task of using their subjectivity, feeling themselves and their patients, without losing objectiveness, which will allow their coherent activity.

In other words, medicine is not a technical activity, even if such trend exists or deforms it. It is also art, and this art goes through affection - the art of placing oneself in the patient's shoes, the art of understanding him and using this to develop the potential of medical action. To do so, physicians must have contact with their own emotions, since they will be affected by the patient's emotions, which will serve as a guide for their art.

How to teach medical students to get in touch with their emotions, with their own mental world? How to teach something that is not learned through techniques? We know that the medical art is based on the identification with professors, masters and colleagues. Medical schools are privileged places to promote this development.

The Medical School at Pontifícia Universidade Católica do Rio Grande do Sul (PUCRS) is certainly one of the institutions in which concern about the physician's formation has promoted not only ideas, but also its practice, based on creative reflections. This practice, careful and in constant evaluation, is a result of the work developed by its professors, stimulated by an interested and participating group from several areas, not only psychiatry. Any fertile and creative movement is possible in case there is no commitment of the institution as a whole.

The book "O estudante de medicina e o paciente: uma aproximação à prática médica" is a result of the work developed by that group. It was organized by Alfredo Cataldo Neto, associate professor of Psychiatry, Ivan Antonello, professor of Internal Medicine, and Maria Helena Itaqui Lopes, associate professor of Internal Medicine. The book is composed of 42 collaborators, professors, physicians and medical students, who clearly, precisely and deeply report aspects of medical practice, focusing on medical students.

The book is divided into three parts. In the first part, "Theoretical background," the characteristics of medical students are discussed. Chapters in part one deal with expectations, fantasies and emotions of freshmen and medical students; factors related to medical vocation; stages and vicissitudes by which students go through; discussion on first contacts with medicine and patients. The second part, "Medicine and its history," approaches how medical practice has been developed in different times. The third part, "Medical experience," provides us with reports by students and physicians about their experience.

Reading this book is essential for professors and physicians involved with the teaching-learning process - in summary, for all physicians, since we are always teaching and learning: from students, residents, colleagues and patients. Being aware of moments, stages, experience and being able to feel them and think about them becomes easier if we can share them with others. This other person is often a colleague or friend who, by listening to us, will serve as mirror in which we can see ourselves. Based on this reflected look, we are able to think, that is, change our emotions into thoughts.

Personal experience, in particular, is a complement that serves to enrich the previous chapters. The latter is clear, provided with adequate references, creative ideas and sensitive examples; on the other hand, personal experience allows readers, mainly physicians, to remember their own experience, reassess them and verify how they have enlightened them. Such review will make personal experience even more useful and creative. It is impossible not to feel touched by the medical students' reports about the admittance test, colleagues, books, grades, corpse, first patients, institutional vicissitudes, pains, traumas, sufferings and joys that are part of everyday life. There are also reports by experienced physicians, who mention their past experience and evaluate its consequences. Readers are surprised by the humanity of the reports, with self-perception of feelings and being able to think about what one has experienced. This is certainly only possible because the students and other authors could be in touch with themselves, thanks to the early stimulation resulting from situations discussed in their everyday life, a consequence of the new curriculum implemented in the Medical School.

Therefore, this book shows us how the art of medicine was transformed into the art of literature. Such art will certainly fertilize readers, arousing emotion and making them think about their own experience. Readers will also be stimulated to get involved in the fascinating adventure of forming prepared physicians, that is, physicians who consider their ethics and feelings, basic conditions to be able to apply their scientific knowledge correctly and creatively. Only physicians with this type of formation will be able to link an exaggerated biologism that dominates current medicine to the exaggerated sociologism that dominates health policies, by replacing what is missing to both of them: affections, feelings and emotions. In other words, the human factor, without which medicine stops being what it is: science and art of understanding and treating human diseases.

Publication Dates

• Publication in this collection
  16 Nov 2006
• Date of issue
  Aug 2006