El final de la vieja medicina

"Hemos perdido la fe en que con comunicación y una exploración cuidadosa es posible modificar el curso de una enfermedad."
David Loxterkamp



Es imparable. La medicina tal y como la conocíamos está abocada a desaparecer bajo un manto de pantallas de ordenador, aplicaciones móviles, complejas tecnologías, infinitas burocracias y profesionales sobrecargados y agotados que no dan a basto en atender los requerimientos de sus pacientes y de los programas informáticos de sus empleadores.

Rescato un interesante diálogo extraído del British Medical Journal entre un médico de familia y un arquitecto. Todo está cambiando demasiado rápido en ambas disciplinas, como lo está haciendo la sociedad en general. ¿Estamos preparados para adaptarnos a esos cambios? ¿Qué valores estamos primando como colectividad? ¿Cuáles estamos desechando?

En el fondo de la cuestión hay un tema filosófico que atañe a la ética y en consecuencia a la política. Los sistemas sanitarios públicos europeos se construyeron con esfuerzo sobre el valor solidaridad, tratando de aportar equidad a todos los ciudadanos, promoviendo la salud y trabajando para aliviar la enfermedad de todos por igual. Las corrientes del poder imperante han socavado este valor promoviendo otros como el beneficio económico y el sálvese quien pueda. No se imaginan lo importante que son los valores, en a penas una pequeña palabra se sostienen estructuras, sistemas, organizaciones y países. Son el cimiento de toda obra humana, si uno los cambia puede hacer que enormes pirámides se desplomen como si fueran naipes. No se crean que es accidental que los pacientes se convirtieran en usuarios y ahora en clientes...

Los médicos estamos en crisis como también lo está la medicina. Hay muchas presiones para que nos convirtamos en burócratas y tecnócratas hiperespecializados. Esto redunda en mayor eficiencia y beneficio para la organización sanitaria que cada vez más estará gestionada de forma privada y lucrativa ergo el beneficio real será para la junta de accionistas o el fondo de capital riesgo que mueva los hilos.

Del interesante texto que adjunto rescato la frase que comienza este post. Los médicos nos enfrentamos a una profunda crisis de fe y no solo en las organizaciones sanitarias y estructuras anexas (sindicatos, colegios de médicos, sociedades científicas). Enfrentamos una crisis de creencias frente a nuestra forma de hacer las cosas. Ya no nos parece suficiente la comunicación y la exploración clínica. Sin tecnología, sin aplicaciones, sin ordenadores... muchos serían totalmente incapaces de ejercer la medicina. Cabe preguntarse si todavía queda algún lugar para la comunicación de calidad, el cuidado de los procesos narrativos del paciente y la exploración física cuidadosa de su cuerpo. Si uno mira a los complejos hospitales no sabría que decir, si mira a los abarrotados centros de salud tampoco. Me gustaría ser capaz de decirles que todavía es posible una medicina humana que permita un contacto de calidad entre la persona en tiempo de enfermar y sus profesionales sanitarios pero todo indica que las férreas reglas del mercado lo van a poner cada vez más difícil.

What doctors have in common with architects—part 1: A manual art

1. David Loxterkamp, medical director, Seaport Community Health Center, Belfast, Maine,
2. Bruce Snider, architect and writer on US residential architecture

Have we lost touch?

DL: Medicine and architecture belong to the physical arts. Their basic units of measure—bodies and buildings—make a sturdy and recognizable impression as you stand before them. But the old standards are changing. Recent developments in genomics, population health, patient centered care, and information technology, such as electronic health records, have changed the way medicine intersects with society. Doctors increasingly work in a virtual environment where touch is relegated to technicians who treat by following doctors’ orders. It is reminiscent of professional etiquette in the 18th century when, as Paul Starr noted, “physicians, as gentlemen, declined to work with their hands; they observed, speculated, and prescribed. Manual tasks were left to the surgeons, who until 1745 belonged to the same guild as barbers.”1

BS: Architects too ply their trade increasingly in a virtual realm. When I began my career in the early 1980s my colleagues and I worked at long drafting tables, sitting on tall stools or standing. The radio played classical music, and we talked to each other while we worked. Today, interns and junior architects sit slumped before computer monitors, earbuds firmly in place, moving only wrists and fingertips. The new digital tools they use are vastly more powerful than my pencil and straight edge. But in embracing them the profession has also abandoned a tradition of draftsmanship and a design process, centered on hand drawing, that went back at least to the Renaissance. How that change will play out—in architects’ relations to their work and in the designs they produce—remains to be seen. I believe it represents an historic watershed, one that gets less attention than it deserves.

How has this loss changed the practice of our professions?

DL: It is commonplace now for primary care doctors to spend more time on the computer than with their patients. We study the screen instead of the patient’s facial expression or posture; follow computer prompts instead of the labyrinthine turns in their story; touch our keyboard but not the body that longs to be examined. We decline to intuit the nature of an illness before blood tests and imaging studies have quantified and objectified the patient’s suffering. Documentation has replaced communication; the inchoate illness of the patient is less true, less reliable—less real—than what is digitally displayed. We have lost our belief that conversation and a careful examination can alter the course of an illness.

BS: In architecture the shift from analog to digital follows generational lines. Many, if not most, firms are still led by architects who trained when the norm was sketching, drafting, and building models by hand and who still use the old tools to design. But construction drawings, what lay people still call “blueprints,” are almost invariably produced by younger associates on computers rather than by hand. My time as a draftsman spanned the crossover period between hand and computer drawing, and I found the contrast between the two regimes stark. When I worked by hand, building designs continued to evolve as I translated them into construction drawings. My creative input was part of the process, and the process was part of my training as a designer. Something about working on a screen, however, cut off my ability to inhabit the building as I drew it, so I became more of a technician than a designer.

The utility of touch

DL: In medicine hands are still needed to palpate a ballotable effusion, crepitant tendon, or fluctuant abscess. Only fingers can detect the sandpaper feel of actinic keratosis, the knot of a trigger point, or the matted induration of a suspicious lump. We learn from limbs that are warm with cellulitis, cool from ischemia, tense in spasm, or pitted with edema. But touch is more useful than the data it provides. A thorough examination conveys our attention to detail, provides comfort, and lays a firm foundation for the doctor-patient relationship. When we touch the patient’s diseased part, we dismantle a barrier to intimacy and the stigma of disease. Our actions signal to patients that we are not afraid of the affliction, nor need they be. It is a gesture of connection and hope, reassuring them of their wholeness despite bodily imperfection.

The basic tools are still needed in patient care: ears to absorb the whole story, eyes to meet a worried glance, hands to touch what is broken or tender. The symbolic connectedness made real in those healing moments is an integral part of the placebo response—a treatment more powerful than most of the drugs and procedures in our evidence based arsenal.

BS: In the old days I could easily recognize a colleague’s drawing by sight, and plenty were beautiful enough to hang on a wall. When the last hand drafting generation leaves the profession, that art form will go with them. This we know. What we don’t know is how an attenuated tactile and kinesthetic connection will affect the way architects design and the buildings they create. An old school architect I know described designing with a pencil and a roll of trace paper as “a trance state … this mystical connection between the brain and the paper, via the hand.” Drawing, she believes, is more than a way to represent and transmit a design; it’s integral to the design process. Drawing, as natural to her by now as breathing, puts her inside the building as she calls it into being. Mastering that skill takes a great deal of practice, practice that young architects—as bright, dedicated, and in love with buildings as any that preceded them—don’t seem to be getting. I don’t know how to identify the quality that distinguishes buildings designed by hand, and I’m sure there isn’t a name for it, but I think we’re going to miss it.

Puede acceder al artículo completo original aquí. http://www.bmj.com/content/350/bmj.h1810