Maria Ilaria Grosso MD, Luigi Saita MD
National Cancer Institute
Via Venezian 1, 20133 - Milan, Italy
 

After reading the Hasting Center report and the many topics proposed, we did not hesitate to choose a subject which, in a certain sense, precedes the considerations regarding the goals of medicine. It concerns the various identities of the physician of tomorrow.

Our analysis will follow this sequence: an introductory statement, the results of a questionnaire on the possible identity of the physician and of oncological medicine in the near future, and a conclusive summing up of the facts.

The subject we have chosen is of special importance to our for various reasons.

We believe that any query directed towards man, the individual who thinks, decides, acts or submits, must always represent the core of bioethics.

Otherwise, there is the risk of rendering bioethic scientistic, reducing it to an endless analysis of the pratical moment of scientific research and technology, leaving man always further behind, with his questions, the search and rediscovery of the values linked to his existence.

We have been involved in the oncological profession for the past fifteen years at a Scientific Institute for Research and the Care of Cancer patients, so that a consideration of the physician’s role in the near future is of concern also from a professional point of view.

We believe our working environment provides sufficient experience to reflect on the question set forth by the Hasting Center Project with regard to the situations one faces in the oncological field. It is a question of difficult actualities for everyone. Difficult for the patient who must face an illness that is often fatal, entailing assistance that is very demanding; difficult for the doctor who, in theory, should be involved both in research and in care.

Also difficult is the new public welfare environment in which scientific clinical activity takes place.

In fact, also in Italy strict control of expenses in the medical field has caused a reappraisal of research and welfare financing, and along parallel lines will obligate the physician to change his views and degree of competence in management and organizational activities.

However, up to now in our opinion the physician has considered the administrator as a despot who is unable to realize the importance of research and incapable of understanding the various requirements that must be met to reach success in the field of oncology. The administrator, on the other hand, possesses the kind of culture and experience that does not easily communicate with the medical world, expecially in a large Italian institute.

The medical world is in fact the sum of a vast number of powerful individual professionals; research is often a frenetic race towards goals measured only in terms of the "impact factor" and scientific publications.

Entirely absent from this "weltanschaung" is the idea of a coordinated synthesis of the various working projects and recognized competence.

In addition to this the Italian physician does not aknowledge either the state or the hospital as the mediator of his actions. These specific recent questions refer to a medical profession already deeply affected by the crisis the western scientific world is facing. The fragmentation of medical knowledge has made it impossible to create, together with other branches of knowledge, a valid interpretation of reality. Thus conceived the medical world is in no position to contribute towards the rediscovery of the sense of man’s questioning.

The patient, on the other hand, suffers because of his illness, and also because today he is even more defenseless and deprived of a meaning for what is happening around him.

This lack of meaning is not due to a void that can provoke new ways of interpreting reality, but simply the repeated, continued recogniting of emptiness. Any illness, expecially if very serious is as cancer, presents as a tecnical problem, both for the physician and the patient.

After this initial presentation of ideas, which is perhaps on the pessimistic side, we would like to submit the results of a questionnaire that was distibuted among a group of oncologists at our Insitute.

These results do not untend to standardize the replies, but rather to offer stimuli for consideration and discussion.

The ten questions regarding the possible identity of the physician and of oncological medicine in the near future were to be answered in the light of current social, economic and cultural changes.

The questionnaire proposes topics of a general nature. We have reserved for our concluding remarks some considerations regarding more existential and intimate aspects of the human qualities of the physician of tomorrow.

Fifty doctors (age 30 to 45) partecipated in this research, operating in all areas of the oncological field (physicians, surgeons, pain therapist and palliative care practitioners). We have syntetized the open replies, trying to identify the more important aspects; multple-answer replies have been put in order according to the consensus received.

C- 2 If no, why?
- 60 % of the physicians consider irreconciliable the containment of health expenses with a more humane medicine, like more kindness and attention dedicated to the patient, more comfortable hospitals. The opinion of these doctors is that caring for the expenses prevents the pursuit of what is good and right for the sake of efficiency and production?   D- Do you think that the medical profession requires today, and will require in the future, very specific human qualities? YES = 98% NO=2% E- If yes, which?
- Willingness to listen
- Respect for the patient’s condition
- Acceptance of one’s personal limitation (existential, physical, moral)
- Empathy
- Gratelfulness

F- Do you consider further specialization necessary in the various oncological fields (i.e., further subdivision of specialization)?

YES = 40% NO=60%

G- Do you think that a humanistic culture will be important in the medical profession of tomorrow?

YES = 80% NO=20%

H- In your opinion, which are the areas of study not strictly concerned with oncological specialisation that should be emphsized in the formation of the physician of tomorrow?
- Health economics
- Forensic medicine and law
- Psychology
- Information and communication systems
- Health management
- Bioethics
- Phylosophy
- Religious aspects
- Other.................

I - Number from 1 to 6 the following bioethical questions, according to the importance and urgency you attribute to each in the care of cancer:
- Communication of diagnosis and prognosis of the illness
- Therapy mutually decided between physician and patient
- Obsinate insistance on therapy or abrupt interruption of all cancer therapies
- Euthanasia
- Genetic screening of tumors
- Controlled clinical experimentations

L- In your opinion, in the near future the Hippocratic Oath will be considered:
- A document which belongs to a remote past - 10% -
- A document which attests to important values in the medical profession, althought perhaps in need of being updated - 90% -

Our impression - after an interpretation of the answers to our questionnaire - seems to confirm the sense of crisis many oncologist are facing today.

This crisis is sustained by the sense of inadequacy caused by the relatively scarce efficiency of most of the therapies we can offer the patient: therapies that produce serious side effects, require mounths of treatment, frequent check-ups and weekly lab tests.

We feel that this crisis is accentuated by the scenario surrounding oncology: very often thriumphalistic and illusory, and in striking contrast to the faces and bodies of the sick we try to cure.

In this context, the addition of necessary economic evaluation is considered by many of the doctors answering the questionnaire as another obstacle in their search and care of tumors and - in any case - an added difficulty working against their efforts.

It seem to us that this prevailing negative line of action reveals the lack of faith in the possibilities and reponsabilities of each of us to offer a personal contribution toward the humanization of medicine: a road which is scarcely influenced by reducing the cost of medical care. We believe instead that scientific research is more directly influenced by the control of resources.

What emerges very clearly is the fact that the physician must have very definite human charateristics in the practice of his profession. This fact must not be intended from a moral point of view, but rathec with a strong sense of obligation, attention and responsability.

Together with the willingness to listen, mutual respect, solidarity and gratefulness, the relationship patient-physician must never cease to take into consideration the limits each has toward the other. These limits in fact - notwitstanding the asymetry that exists between physician and patient - represents the fundamental point of contact with the patient. The acceptance of this fact represents the recognition of a fundamental reality without which we do not think the physician and patient will be able to cooperate in choosing the cure best suited for the general good of the sick person.

On the one hand, the explicit request for a humanistic culture as a background for the medical profession - more knowledge in the fields of health economics, psychology and bioethics.

On the other hand, the negative response regarding a greater future subdivision of specialization in the oncological field. Surely this is a further affirmation of the importance of providing a less scientific formation, taking into account our cultural roots and the discoveries that history proposes and imposes.

Therefore, to reply to the consideration implied by the question "who will be the physician of tomorrow ?", we should like, in conclusion, to go beyond the concrete description of a typical medical doctor, specifying his background from an anthropological and existential point of view.

We would ask a physician of tomorrow, and also of today, to be willing and able to undertake a very serious study and interrogation of man’s existence, so that his partial contribution will become part of the general progress in other branches of human knowledge; so that his activity will go toward the goal of reaching a well-being that will also be a good-being.

Both physician and patient can together, and also by virtue of their differences, meet sickness and death not only as an obstacle or crisis, but as a way of facing, with courage, the provocation and challenge that this condition elicits in all mankind.

Only an authentic inter-relationship can create the basis which allows the "care" and the "caring for" to continue and hand in hand in the oncological profession, putting and end to the sad and dismall attitude which distinguishes the scientist who follow only the active phase of oncological therapy from the doctors who continue to assist those patients no longer of interest for research.

The oncologist of the future will also have to learn to assist without being able to intervene, he will have to discover within himself the courage to cure without recovery.

Only by sharing the obscure and passive regions of the illness can one find hope, which is a distant light that flickers in the language of exchanged glances and words of tenderness.