Is medicine sick?

Image: Marco Buti / Jornal de Resenhas


Comment on the book “The doctor and his interactions” by Lilia Blima Schraiber

When I finished the medical course, in the distant year of 1962, I heard the phrase with which graduates were usually toasted, a phrase that mixed aggressiveness and realism: “You are going to stop being an important doctoral student and become a shitty little doctor”. And indeed, I was not prepared for real-life medicine.

At the Faculty he had learned a lot: the anatomical location of the organs, their functioning, the alterations they suffer in the disease; I learned how to use means of diagnosis and treatment. All teaching, however, apparently proceeded from the assumption that we would work in the best of all possible worlds, celebrated by Voltaire's Pangloss. The reality check was, of course, brutal. But it can be understood, and to that end this book makes a very important contribution.

The author does not lack credentials. Physician, specialist in Public Health and Health Planning, lecturer in Preventive Medicine at the Faculty of Medicine of USP, Dr. Schraiber is currently a full member of the UNESCO Chair in Education for Peace, Human Rights, Democracy and Tolerance. She is also editor of the journal Interface – Communication, Health, Education, and scientific consultant for several publications.

“I seek to analytically distinguish medicine as knowledge from medicine as work”, says the author in the preface. Absolutely crucial distinction, as we have just seen. And that has historical roots, as is the case of medicine itself.

There is usually talk (at least in terms of Western culture) of a first, magical-religious phase (the phase of priests, sorcerers, shamans), followed by a second, empirical one (the landmark here is the Hippocratic school) and a third, which coincides with the advent of modernity: it is the scientific phase, marked by anatomical and physiological studies, the microscope and the Pasteurian revolution, and then by all the fantastic technological advances registered from the end of the 19th century onwards. changed due to socioeconomic changes. The author is interested in the recent (and profound) changes in this area that have occurred in Brazil, and which configure two basic types of professional practice: “liberal and artisanal medicine until the 1960s and business and technological medicine since then”.

Although in the past doctors even worked as slaves (in ancient Rome), liberalism ended up becoming the preferential way to carry out their work. A freedom based on knowledge: the doctor knows what the patient has, he knows how to treat the problem, he knows the best form of care, and this knowledge gives him, or used to give, power and freedom of action.

But, on the other hand, medicine deals with unpredictable factors, including and mainly related to the cost of illness: in most countries, expenses with medical assistance grow at a faster pace than inflation, putting people in a distressing situation. The State had to intervene, and the private sector saw this as a risky but promising market. Nowadays, in Brazil, only a small number of physicians carry out their activities in private offices. Most professionals are salaried in the public sector, or work for health insurance.

And how do doctors react to this situation? This is an interesting question. It could be answered through one of the usual polls; but Lilia Schraiber opted for another model, that of the personal interview. She worked with two groups of doctors, an older one (beginning of professional life between 1930 and 1955) and a newer one (beginning of professional life between 1980 and 1985), thus characterizing the two periods mentioned above. As the interviews were long, the groups had to be small (17 physicians in total). But, and this is the reasoning behind this type of research, what is lost in surface is gained in depth.

An individual testimony, and this is valid in the case of doctors, who have very similar trajectories, can be paradigmatic, exemplary. In addition, as the transcripts (three from each group) show, the narrated stories exude authenticity, which impress and sometimes move the reader. It is the “hidden face” of medical practice that then appears. A complaining face: “I should have studied law”, laments doctor Nelson, born in 1912 (not without reason: law, as the book itself shows, has always been a more liberal profession than medicine). And he elaborates: “We, the clinical physicians – and I believe that the specialists too – are not doing very well, because there are these agreements that are hindering us. Not only the INPS, but also these agreements, where we earn a pittance. You are obliged to make this clinic run”.

The doctor stands between the sea and the rock, often serving as an outlet for the population's nonconformity. Doctor Cristina says: “The father arrived with the dead child. And a colleague who was there, a pediatrician, said she was dead. The father was furious because the pediatrician said she was dead. 'But then' – he said, – 'she died here'. He took a stick, broke her car window ”. And it's a grueling day: “I work from 7:00 am to 23:00 pm”, says Dr. Bernardo. A grueling regime that generally does not allow establishing a good relationship with the patient. On the other hand, patients, increasingly informed (TV, internet), require high-tech tests that are generally expensive.

The author concludes that a new transformation is needed in medical practice. This time it is not scientific or technological; it is in the way of exercising the profession, in the relationship with the patient. It is a discussion that is just beginning, but that is urgent, and for that, Lilia B. Schraiber's book brings important elements. Medicine is sick, and it is works like this that will help to make a diagnosis of (to paraphrase Freud) “discomfort in the medical culture”, proposing solutions that are feasible and good for the population, for professionals and for society in general. .

* Moacyr Scliar (1937-2011) was a writer and professor at the Faculty of Medicine of UFCSPA. Author, among other books, of naughty dogs month (LP&M).

Originally published on Journal of Reviews no. July 3, 2009



Lilia Blima Schraiber. The doctor and his interactions – the crisis of bonds of trust. São Paulo, HUCITEC, 254 pages.




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