Laura María Moratal Ibáñez
Departamento de Salud Pública. Facultad de Medicina. Universidad de Buenos Aires (Argentina).
Correspondence: Laura María Moratal Ibáñez. Escuela de Salud Pública. Marcelo T. de Alvear 2202. 1121. Ciudad de Buenos Aires (Argentina).
Received 22 April 2007; accepted 29 May 2007
There are no diseases, only patients. We repeat this timeless adage with our students as though after stating it the issue will be fully understood by them and our consciences assuaged. It is a short phrase, easy to memorise, that makes us look like lords of humanitarianism. But then, later, students enter the wards and see how the theory crumbles when they hear all the health staff referring to their patients as, for example, That pancreatitis we received yesterday, or That pneumonia due to penicillin-resistant penumococci…. Terms such as this are ever more frequent, as though they had come from some kind of flow chart drawn up somewhere that we have copied word for word so that we will not be considered “backwards”; a very denigrating epithet for today’s doctors, who are more fearful of being considered out of date than dehumanized.
To fall behind, to fail to adjust to the new supranational indications or to the counselling of the last “paper”, is almost tantamount to the sin of being “antiquated”; of not being in tune with the latest fashion; of being in a rut… . And in an unbridled career towards prominence, if not competence, the great principles are forgotten. The student who glimpses the chasm between the theoretical wordiness that appears in technical manuals and is repeated in class, but is then not lived up to in daily medical practice, is confused -and justly so- and he or she finds it hard to remember that behind any case referred to with abbreviations and numbers there is always a human life, a real existence, with all that person’s intellectual and emotional baggage. A singularity in the feelings and sufferings typical of that person’s gender, ethnicity and social class, as also his own fears according to his own experiences. Thus, we refer to a unique and sentient being, with a unique pathology from the psychological and social perspectives.
There are no diseases, only patients… This is not a story, not a pretty little phrase, but a great truth, even from a pragmatic point of view since the result of its being put into practice will depend on it being remembered and reflected in the daily life of health staff. Even cold, lifeless numbers show that the greater the patient satisfaction with the attention given, the better the compliance and adhesion to the prescriptions and indications made1, and hence the better the health outcomes in terms of shorter treatment times, less time spent in hospital; fewer relapses and complications, a lower rate of absenteeism at work; fewer health expenses, etc.
Accordingly, understanding patients by listening to their personal problems is not “a bow over the package” of diagnosis and correct practice, because if physicians fail to arouse patients’ confidence in them, the sick will fail to follow their indications. As a result, infections will prosper and propagate; drugs will lose their effectiveness, complications will arise, and all medical activity will finish into a failure, that the technology will not be able to solve. Thus, the only way to solve such problems is to listen patiently to the voices of our patients and consider their future outcomes, deciding on which possibilities will be best for each of them.
But how can today’s medical instructors perform this task, where each day is increasing the number of students who are in conditions to accede to the University. In practice, there is increasingly less time available for teaching, owing to the academic demands of research, administrative duties, attendance at congresses etc. All these are obligatory activities for medical instructors if they are not to be superseded by others who know, and indeed play by, the rules of the game. How will it be possible -with the little time available- to transmit to our students something that is not informative, nor a skill, but an ethical and humanistic concept that is invaluable in medical practice?
Medical instructors have always made huge efforts to discover some kind of efficient methodology aimed at teaching ethical attitudes, and in the humanitarian professions this has always been a key issue2. The current loss of a direct relationship between instructors and their students3 has resulted in a failed transmission of appropriate attitudes. It is imperative retrieve this kind of teaching practice, because the kind of mechanistic and technical training that has prevailed over the past few decades has caused no end of problems in the physician-patient relationship; now apparent in the large numbers of patients who abandon treatment, consult alternative styles of medicine, and become involved in exponentially increasing numbers of malpractice suits.
The use of the cinema as an educational resource, in times when life is dominated by images, has always been a permanent referent of film makers, and the list of films addressing this issue is long and includes films of great relevance4. We should be very grateful to the script writers and directors who have addressed medical issues, for they have always exercised great care to show -truthfully and with great clarity- that disease is not the “star of the film”, and certainly neither no pathogenic substance. Always, the people and his lifes in the society occupied this place . In the filme the agent is only the emergent of a contextual situation that will be the determinant of the greater severity or persistence, and that are ultimately responsible for the quality of life of those affected, because this depend on the patients’ own possibilities and also on the prejudiced view that society might have about this dysfunctions or illnesses.
The cinema, through its motivating aspect, allows both the incorporation of new content and the possibility of analysing all the components involved and, above all, by means of appropriate debate it allows recognition of the opinions of the students themselves in their assessment of which parts of those components are important or missing. Today more than ever, in this world careening towards the training of “superspecialists” it is necessary to recover an integrated view of health problems, because only with this type of intervention will it be possible to find solutions to the problems that affect all human communities.
The showing of films in medical centres is an ideal vehicle for highlighting such a holistic view of health issues. This has sometimes been overlooked in traditional teaching practices or has been hindered in the early years of students’ training through limited views of organs and tissues, without them first receiving complete information about the human organism, including its bio-psycho-social dimensions.
In each of its scenes, a good film should reflect the socioeconomic and health background in which the events unfurl, together with offering a good portrayal of the historical setting that determines the characters’ lifestyles, eating habits, self-protective behaviour and charitable actions and the effects of these aspects on the health of the population. And the inverse is also true: a good film should portray the modifications in the cultural life of the population that are brought about by the diseases themselves, according to the interpretations that each culture has made of them according to its beliefs.
The cinema allows us to view -in a comparative way- the pathology in question at different historical moments and in different social or personal situations, so that students can be left in no doubt that the problem caused by the disease may be the same but the result is always different. In all sincerity, film makers have always had a very clear idea about these concepts, because they have never focused on the disease: only on the patients, their lives, their struggle to survive, and their personal circumstances. This is therefore a lesson about humanitarianism and integrity, which as physicians we are fortunately able to use to students’ benefit in our teaching activities.