Internists reflect at ICOMEM on how the doctor-patient relationship has changed and where it should go with an eye toward humanism and techno-ethics
The incorporation of technologies into routine clinical practice is causing a “transformation in the social relationship model and also in the health care model”
It is urgent to reorient the doctor-patient relationship from the perspective of techno-ethics without forgetting the humanistic approach of person-centered medicine and avoiding a clinical practice based only on data and evidence
Technology “must not displace the essence of the doctor-patient relationship, based on communication, affection and shared decision-making.” Technological humanism should be advocated in medical praxis
Emphasis has also been placed on the fact that health professionals are “technically prepared” to face the end-of-life process, but that it is key to train future doctors in “communicating bad news or knowing how to transmit information in a friendly and empathy for shared decision-making with the patient”
Internists from the Spanish Society of Internal Medicine (SEMI) discussed how the doctor-patient relationship has changed, what it is like and where it should go at the “IV SEMI Patient Conference: New patterns in the 21st century”, held this Last Wednesday at the Illustrious Official College of Physicians of Madrid (ICOMEM) and organized jointly by SEMI and the Francisco Vallés Institute of Clinical Ethics.
During the course of the meeting, the rights of patients, respect for their autonomy, techno-ethics and how technology has contributed to changing the relationship between doctor and patient, as well as the need to achieve a person-centered and humanistic medicine. In the current context in which we live, it has become clear that technology is a “very useful” tool that has been incorporated into clinical practice so that diagnostic and therapeutic procedures are more precise, but “it should not displace the essence of the doctor-patient relationship that is based on communication, affectivity and shared decision-making”.
The meeting was opened by Dr. Jesús Díez Manglano, president of the SEMI, and by Dr. Arantzazu Álvarez de Arcaya, SEMI coordinator for patient relations and coordinator of the Hospital Medicine Clinical Management Unit of the Hospital Clínico San Carlos.
Dr. Díez Manglano reiterated at the inauguration that for the medical profession in general and for specialists in Internal Medicine, in particular, “the voice of the patient is and must be fundamental” and has emphasized the “comprehensive and holistic vision that characterizes the work of the internist”. Also in that he “urges greater attention and dedication from the clinical field to the end-of-life process”, and in this sense, he recalled the consensus promoted by SEMI-SPMI on good practices in the end-of-life process.
In the words of Dr. Arantzazu Álvarez de Arcaya, SEMI coordinator of patient relations: “new technologies have changed the way we relate to each other and this is something that we must all learn to continue creating high-value medicine based on affectivity. The challenge is to know how to integrate new technologies to promote humanistic medicine”.
The end of life process
During the course of the day, they reflected on the end-of-life process, a stage in which patients find themselves in a situation of “great vulnerability”, both physical, psychological and even moral; “without forgetting the family and close friends, also very affected by the situation from the emotional and vital point of view”.
“The doctor is very prepared to face the end of life technically: how to interpret the tests, make the prognosis or sedation. However, he would need more training in communication skills as well as more ethical training, to face the end of life, moment in which difficult decisions are shared with the patient, taking into account their socio-family environment, with a high emotional cost”, indicates Dr. Álvarez de Arcaya, who emphasizes that “care at the end of life must be adequate medically, but also close, empathic and compassionate. In short, human”.
Humanistic medicine beyond mere evidence and data
The importance of humanistic medicine has also been highlighted and that a clinical practice focused solely on evidence and data should be avoided. “The clinical relationship must be reoriented to effective communication between two people. Technology is important and necessary, as is respecting the autonomy of the patient. However, the best thing is that someone is directing the entire process with common sense and clinical reasoning, that is, a good doctor. Otherwise, medicine would be reduced to just data and tests. It would be reduced to a consumer good far from its true foundation: the best health care for patients.”
In this sense, Dr. Álvarez de Arcaya reiterates that “medicine is a sum of science and humanism. Doctors treat people, and if we want to make medicine centered on people we have to know, in addition to the scientific aspects, those related to with psycho-emotional factors and with social complexity. This has been especially relevant in the last two years, during the period of the COVID-19 pandemic.”
Techno-ethics: How to make technology and humanistic medicine compatible?
Throughout the different tables, it became clear that technology has broken into our lives and has modified our knowledge, our behavior and our way of relating. And in the environment in which we currently live, close to technolatry, reflections arise such as whether we should do everything we can do, and how to apply ethics to technology (techno-ethics). Technology solves social problems and, at the same time, is causing the need to rethink how we should act, redefine concepts and review the principles on which we base our actions. “It’s about avoiding the misuse of technology so that it doesn’t interfere with people’s well-being.”
In this sense, it has been stressed that “the good doctor must be able to integrate scientific knowledge with other non-technical skills that are essential to develop what is called ‘medical well-being’, among which are communication skills and in managing emotions.Internists as specialists with a holistic vision, we have that ability to integrate all aspects of the person: physical, psycho-emotional and social, all of which are essential to be able to accompany our patients and their families throughout throughout the disease process, until the end of life,” says Álvarez de Arcaya.
However, it was also reiterated at the conference that “these skills have to be taught from the Faculties of Medicine. Communication is fundamental in the work of the doctor; for example, knowing how to communicate bad news is decisive in helping people to minimize the emotional impact of the disease; or knowing how to transmit information in an appropriate and friendly way to make shared decisions and, thus, be able to face serious illnesses from all perspectives”.
Evolution of the doctor-patient relationship
The classic doctor-patient relationship was based on beneficence. That is, thinking about what the doctors believed was the best for the patient, they decided for the patient himself. This created a type of relationship that has been called paternalistic. In recent decades, the change has been radical, because the rights of patients have been introduced and, especially, respect for their autonomy. This has completely transformed the clinical relationship pattern. An information-based model (informative model or pattern) has been proposed, in which doctor and patient exchange information and the patient decides. However, this model has shortcomings, because many patients want, in addition to information, the doctor’s advice. A doctor’s recommendation on what is best for him. This pattern or model has been called deliberative. In the deliberative relationship, doctor and patient exchange information, but also their opinions and assessments about what is best.