Alberto J. Muniagurria
Claude Bernard affirms, from the origins of the physician's history, that the doctor was oriented to attend to the physical ailments of the patients, but also to teach and carry out research. Also from its beginnings, it had the progressive option of going in one of the three activities as a priority. Although in practice, to a greater or lesser extent, he will also act in the others.
The healthcare function , which is the most evident of professional activities, is perhaps the first attraction for anyone who has this vocation, but teaching is also part of and is inserted into every action of the medical doctor. Teaching derives from the latin voice doctor, docere . And teaching is developed in the training of students, with patients, and with society in general.
For its part, research also constitutes an indissoluble function in professional actions. From Hippocrates the doctor observes, controls, records and compares his findings.
It is thus, then, that from their first representatives, the physician´s worked for the health of their patients, whether attending, investigating or teaching. But these concepts, which have been paradigmatic in the galenic action, have been undergoing modifications in the way of applying them, in the course of time. Numerous factors have contributed to this, especially in the last hundred years, in the last century, which has been the one that has produced the most changes in human customs from the bottom of history.
The orientation of the curricula developed by the medical education centers played an important role. In 1910, the German expert Flexner, in a report requested by several American universities, defined new teaching methods, linked to the new technology that emerged explosively at the beginning of the century. The approaches of this expert in medical education promoted a change, in university teaching and in their curricula, and therefore in the customs of application of professional practices, in their areas of work and in their knowledge and skills. This was developing an impulse to what was known as specialism (special dedication to an organic apparatus or system with the objective of deepening the mastery of a certain area through intensive training).
The specialism then divided the patient into apparatus and systems (circulatory, endocrine, digestive, etc. etc), and made it possible to learn more about less, much little, and promoted with this orientation the growth of science in each area. In this way, the professionals found in the specialties a more limited, orderly and predictable work.
With the advance in the frontiers of science and technique , both life and death could be modified. Knowledge of genetics, new diagnostic procedures through biotechnology, regulatory sciences and permanent advances in the therapeutic fields, both physiological and pharmacological, and surgical interventionism, and in the field of mental processes, contributed their own , generating changes, progressive, evolutionary and overcoming scenarios on itself. In the past, the nature of diseases could not be modified in the actions of doctors, except for surgery that generally cut or removed diseased tissues.
Another great change that developed in society, in the past two hundred years, were the advances that occurred in the respect for the Human Rights and this had its impact on medicine, logically, especially in the areas of relationship of the doctor with the patient . . With the Declaration of the Men's Rights, in 1789 the right of people to decide their destiny for themselves arose. In reality, these ideas only knocked on the doors of medicine in 1970, according to Pellegrino, "..... it was only then that we began to speak of autonomy"(1) or free will, that is, the capacity for self-government of individuals, a quality inherent in rational beings that allows them to choose and act in a reasoned manner on their decisions. A growing rebellion had emerged from society towards authority and autocracy. This autonomy was reflected in what was known as informed consent . (*)
Over the years, this document lost its original motive and became a mechanism for legal protection of physicians in medical malpractice approaches. Thus, progressively, the doctor / patient relationship went from being an episodically conflictive relationship to an essentially conflictive relationship.
The health insurance systems and the progressive intervention of the State, with its regulatory, legal and judicial systems and thus the participation of the different national, provincial and municipal entities, produced a change in the customs known as the doctor/ patient relationship to be today a medical/ patient/ family/ society reality.
From its origins, the doctor's task was oriented with an attitude of beneficence, (in the literal sense of the latin voice bonum facere , to do good). Through the Hippocratic oath the professional acted mainly for the good of his patient. In general, the family also acts for the same reasons, and sometimes applies its right or autonomy, as does the patient, while society controls, audits and eventually judges in situations of conflict.
In other words, in the evolution of new circumstances, the doctor, historically accustomed to a single relationship with the patient, saw the incorporation of family members, health systems, their own interests, and educational needs into the bond continues, and eventually to society with its laws and regulations.
Technical and scientific advances also influenced the development of new needs for healthcare environments, which were gradually incorporated. These new settings, appropriate to provide highly complex care, promoted areas of intensive care, coronary care units (CCU) and special care units (ICU). These modifications contributed by their own to separate or create distances between the doctor and the patient. All this movement reached its maximum expression in the United States during the 60s and 70s. The developing countries, in their healthcare centers, were building the same changes.
It has not been studied in how much of the time in the clinical practice, is developed near to the patient. In this sense, Dr. Faith Fitzgerald of the University of California, found that in his institution, in the room passages (medical rounds), the doctors spend 9 minutes with the patient at his bedside, and 32 minutes in the infirmary writing the evolution and indications. Coinciding with this observation are publications showing that old-guard physicians spent 82% of their time with patients, versus 53% of younger ones. If this is extrapolated to the general population, all doctors spend 35% of their time, in direct contact with patients, 4% with students and residents 2%.
In 1920 voices were raised in the world that began to alert about the withdrawal of the doctor from his patients. These voices clearly raised the difficulties they observed in the healthcare system, as well as the disregard for clinically and clinically trained medical care, all of which occurred in both developed and developing countries, the so-called Third World.
The meeting of the World Health Organization in Russia in the town of Alma Ata proposed ... "essential medical health care should be offered within the reach of all individuals and families in the community, by means that are convenient for them acceptable, and at a cost that the community and the State can bear, with health education, prevention and promotion of this, nutrition, drinking water, maternal and child care, family planning, treatment of endemic and traumatic diseases, as well as the supply of essential medicines ... "Health being a right, and defined as ..." a complete state of physical, mental and social well-being ... ". (5)
Primary Health Care was defined as a strategy to obtain global health by the year 2000. The doctor, within this strategy, was the agent of change.
The levels of care proposed for contacts between individuals, the community and the health system were the following steps of action:
The individual and the family
- The health agent
- First level of care (Basic Care)
- Second level of care (Intermediate step)
- Third level of care (High complexity)
In developed countries, where there are also problems in access to health,
Primary Medical Care was referred to as that which is exercised at the first level of care. It was considered as a level of care .
In these countries, the proposal was that care, at the first level, should start with medical professionals, and not with health agents, that is, that the doctor control the entrance to the health system, in charge of the first contact with the patient, .. "regardless of the state of physical, mental or social health of this" ...... With this objective in postgraduate careers, the proposal for a specialty in Primary Care, Family Physician, was promoted.
In the United States the process was complicated. Faced with the possible health plan promoted by the government of president Clinton that promised access to health for all citizens, millions of dollars were mobilized to create advertising aimed at convincing the electorate that the plan had "... socializing aspirations and created an affront to the Darwinian principle that every American has the right to live without state aid. "(6). The American people have a deep-rooted culture of self-effort. According to Kumar Sen, the Nobel Prize in Economics "... is a basic factor that enables them to be self-sufficient." (7). Only in 2010 in the presidency of Barack Obama, the project resumed, and general assistance was approved as a right of the Americans. President Trump finished with the proposal.
In previous years, the training of doctors was carried out in hospital wards. The outpatient care space became an important place for medical training, Ambulatory Medicine was ranked. Along the same path, the different specialty societies rehabilitated their role in Primary Care.
The model of doctor was oriented, in the curricula of schools, to be more concerned with his patient than with the techniques or knowledge acquired. The aim was to work in the environment of the disease, with an educational and preventive attitude. This is how the ambulatory and home care scenario was rescued.
All these proposals and changes were developed in Argentina. In the 90's the government launched the PMO (Compulsory Medical Program) programs. The new tendencies tried to cover an empty space and make it hierarchical. The goal was to bring the doctor closer to his patient. That the doctor attended to the problems of his patient, rather than showing a reactive attitude to the pathologies that he presented, which was the norm in the training programs of yesteryear. Comprehensive, continuous, comprehensive care, the professional acting as coordinator of the patient, male or female, child or older adult, "... throughout their life from birth to old age if possible".
The changes were happening so that the different levels, officials and professional associations, returned to the style of doctor that presents the profile of high scientific training, comprehensive management of family and community group problems. A primary care strategy was promoted, which does not mean primitive or second-class care aimed at a single model of rural or peri-urban population, but rather as the gateway to health, with universal accessibility to different levels of care when circumstances proper to the needs so require. A medical model of general training was promoted, scientifically endowed for preventive and curative comprehensive care, typical of the first level of care, and trained to interact appropriately with the rest of the levels.
This demanded - and demands - to know the reality of the environment, to recognize the different regional characteristics, the prevailing pathologies, with profound contrasts in needs, demographic and socio-economic-cultural variations that vary from rural to urban, emergency towns, etc.
The different levels and lifestyles require diversified health services that are in a position to respond to the healthcare demand that ranges from the social pathology of poverty to those of the developed world. From cholera to hypercholesterolemia.
This imposes an elasticity in the models of practices and education and training models that does not ignore the realities or wishes of each professional, but neither those of the environment where they must carry out their work. In our institution Centenario Hospital since 2004, the Day Hospital has been serving the ambulatory practices to the local population.
What seemed linear and simple in definition became more complex. From the origins, focused on the care of patients' physical ailments, teaching and research, it became a new, broader role, adapting to numerous variables that were modifying the very essence of being professional,
Since the 1980s, the Chair of Clinical Semiology, in its science and art, has strived to rescue this model of medicine. This activity, both in the healthcare, teaching or research function, with all the vicissitudes and difficulties that come across it, is called to be, from its origins, the queen of the professions. It is based on her love for the human being, and for always placing the patient first and included in the society, of which she is a part. With honesty, integrity and altruism, commitment to excellence, respect for duty and, ultimately, honor.
Thus, work has also been done to participate in the development of a registration instrument, of this professional model, the Problem-Oriented Clinical History (HCOP).
The challenge is to build a doctor, not loaded with information, like Funes the memory, character of Borges, who was not able to conceive or build new ideas, because he was only capable of remembering and reciting.
Finally, to paraphrase Dr. Juan Manuel González, a distinguished Rosario Medical School professor of Semiology. "Knowledge is not the same as being informed. Information must be indispensable to face problems, cover them and embark on their resolution"
(*) Document signed by the patient before receiving a diagnostic or therapeutic procedure, stating that the procedure to be carried out has been explained in detail