The good old days
1998; Elsevier BV; Volume: 352; Issue: 9144 Linguagem: Inglês
10.1016/s0140-6736(98)09196-x
ISSN1474-547X
Autores Tópico(s)Empathy and Medical Education
ResumoNostalgia, defined as “… a longing for something far away or long ago”,1Webster's New Twentieth Century Dictionary. 2nd edn. Collins World, USA1978Google Scholar permeates our attempts to redefine the relationship between patient and doctor in the light of societal evolution and recent scientific developments.2Glick SM From Arrowsmith to The House of God, or “Why Now?”.Am J Med. 1990; 88: 449-451Summary Full Text PDF PubMed Scopus (4) Google Scholar This longing suggests dissatisfaction with the present and, perhaps, a conviction that things used to be better. “The ancient, very successful, physician-patient relationship requires many adjustments and alterations, and there now prevails a new basis for interaction…”.3Angrist AA Introduction to symposium on humanism and medical ethics.NY State J Med. 1977; 88: 449-451Google Scholar From where does the nostalgia arise and on what do we predicate our assumption that, in the good old days, we were less harried and more caring? A prime source of knowledge about yesterday is memory—a faculty with many failings, especially among those of us who have arrived at the age of benign forgetfulness. Do I really remember what it was like to study medicine 40 years ago and to begin practising it shortly thereafter? To what extent can I depend on my recollection of those “happy” days, distinguished, so many believe, by more compassionate and empathetic physicians than those of today? On the one hand, so much has improved since then with respect to diagnosis, prevention, and therapy, that practice has changed almost beyond recognition. We can now prolong the lives of patients with chronic congestive heart failure4Drugs for chronic heart failure.Med Lett Drugs Ther. 1996; 38: 92-94PubMed Google Scholar and diagnose lesions of the retroperitoneum, formerly invisible, by means of ultrasonography. Additionally, we have laparoscopic surgery, hip nailing and replacement, anaesthetic techniques enabling lengthy and complicated operations, as well as immunisations not dreamt of a generation ago. On the other hand, it is important to remember that we applied the means at our disposal way back then with enthusiasm, never feeling either impotent or nihilistic when it came to prescribing treatment. There are those who speak of a “… relegating of individual human values to a second order of priority in relation to applying the advances of modern, scientific, technologic medicine”.5Naughton J Medical ethics, humanism, and preparation of modern physician.NY State J Med. 1977; 77: 1448-1451PubMed Google Scholar Again, we are told that “Our technical advances, together with the accompanying changes in our social structure, confront us with a variety of problems which continue to challenge our former and accustomed ways of thinking”.6Nordlicht S Teaching humanity-oriented ethics.NY State J Med. 1977; 77: 1452-1454PubMed Google Scholar Both statements suggest a kind of “either or”, advanced technology and highly skilled operators versus compassionate, empathetic, altruistic physicians. Our calling is not a scientific one, although it uses science as one of its instruments; doctors are not servants of nature, the human race, or life but of the individual.7Fox T Purposes of medicine.Lancet. 1965; ii: 801-805Abstract Scopus (27) Google Scholar Thus, there is no such thing as “scientific, technologic medicine”, only a helping profession employing and deploying mechanical means for the benefit of suffering humanity. In 1927, Francis Peabody wrote: “The secret of the care of the patient is in caring for the patient”.8Peabody FW Quoted in: Fox T. Purposes of medicine.Lancet. 1965; ii: 801-805Google Scholar This suggests that 70 years ago, when a radiographic apparatus and an extremely unwieldy electrocardiographic machine were about as technically advanced as you could get, the question of compassion versus technology was very much in the air. Had all physicians been caring and humane at that time, there would have been no need for Peabody's dictum. That humane medicine is, somehow, a function of an unhurried pace and a low-tech approach has been pointed out.9Volpintesta EJ Empathy: can it be taught?.Ann Intern Med. 1992; 117: 700PubMed Google Scholar Moreover, it has been suggested that empathy is a natural endowment for most of us, but that we tend to lose it along the way as we are socialised and professionalised in the calling of medicine: “As I know them, college students start out with much empathy and genuine love—a real desire to help other people. In medical school, however, they learn to mask their feelings, or worse, to deny them. They learn detachment and equanimity”.10Spiro H What is empathy and can it be taught?.Ann Intern Med. 1992; 116: 843-846Crossref PubMed Scopus (242) Google Scholar But might not the process also operate in the opposite direction? Students and doctors in training are kept anxious and uptight by their lack of experience and their fear of missing an important, treatable condition. With the acquisition of a certain amount of self-assurance, matters become more relaxed between them and their patients, and compassion can emerge “from under” the differential diagnosis. Both endogenous and exogenous factors have been noted in our loss of humaneness and altruism,2Glick SM From Arrowsmith to The House of God, or “Why Now?”.Am J Med. 1990; 88: 449-451Summary Full Text PDF PubMed Scopus (4) Google Scholar whether at the personal or the historical level. The exogenous kind is linked to societal changes: managed care, a proclivity to litigation, the increasing cost of medical education, living under the threat that future rewards will be wiped out by economic, military, or environmental calamity.5Naughton J Medical ethics, humanism, and preparation of modern physician.NY State J Med. 1977; 77: 1448-1451PubMed Google Scholar, 11Graef I Decline of altruism in medical care.NY State J Med. 1977; 77: 1454-1456PubMed Google Scholar, 12Dubovsky SL Coping with entitlement in medical education.N Engl J Med. 1986; 315: 1672-1674Crossref PubMed Scopus (51) Google Scholar “Perhaps people now feel a more urgent need for immediate gratification because any other goal seems increasingly evanescent.”12Dubovsky SL Coping with entitlement in medical education.N Engl J Med. 1986; 315: 1672-1674Crossref PubMed Scopus (51) Google Scholar Endogenous factors contributing to the profession's malaise, nostalgia, and maladaptation include changes in physician motivation away from service to one's god and fellow-man and towards an emphasis on rights as opposed to duties.2Glick SM From Arrowsmith to The House of God, or “Why Now?”.Am J Med. 1990; 88: 449-451Summary Full Text PDF PubMed Scopus (4) Google Scholar In addition, we now experience the exhilarating “fix” of power to cure and so derive less satisfaction from extending comfort and reassurance: “Obsessed with the miracles of modern medicine and technology, hynotized by their own hype that medicine can cure all, physicians have much less patience and time for the patient who ‘does not respond’, “who cannot, or ‘will not’ be cured”.2Glick SM From Arrowsmith to The House of God, or “Why Now?”.Am J Med. 1990; 88: 449-451Summary Full Text PDF PubMed Scopus (4) Google Scholar Finally, we have become overly dependent for gratification on popularity and patient adulation: “The public climate, particularly the media, has not been charitable to the medical profession of late, and many physicians, desperate for positive feedback and reinforcement from external sources and dependent on this praise, are frustrated”.2Glick SM From Arrowsmith to The House of God, or “Why Now?”.Am J Med. 1990; 88: 449-451Summary Full Text PDF PubMed Scopus (4) Google Scholar Several basic facts must be considered when the evolution of the physician-patient relationship is discussed. First, changes in society and scientific developments are frequent sources of strain. Second, our perception that doctors were more compassionate, empathetic, and caring when there was little they could do to combat disease is almost certainly fallacious since, as far back as 70 years ago, they were being preached to about what it means to “care for” the patient. Third, even though to us it may seem that the physicians of bygone days were therapeutically impotent, a perusal of older medical textbooks reveals no lack of enthusiasm for treatment.13Herman J Therapeutic nihilism?.Isr J Med Sci. 1996; 32: 259-264PubMed Google Scholar Fourth, our recall of the degree to which practice was humane, when, the more senior among us set out on their careers some 40 years ago, is notoriously untrustworthy and there is no solid evidence that we should be nostalgic for yesterday. Last, nostalgia implies dissatisfaction with the present, something that has more to do with the process of ageing than with demonstrable differences between “then” and “now”. Recognising its origins is important, since we cannot, in any circumstances, stem the tide of change in the societies in which we live.
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