Portuguese Version

Year:  2002  Vol. 68   Ed. 4 - (1º)

Editorial

Pages: 466 to

PDF PT  

The time to define a specialty

Author(s): Henrique Olival Costa

Keywords: -

The correct understanding of facts and its consequent comprehension are some of the most vital qualities of human beings. The assumed predictability, inherent to the evolution of facts, propose a close link between past, future and present, as if obscure nature mechanism could indicate future steps. This belief in prediction of events has served as a basis for those who are interested in studying and helping the others since the time of Newton and Laplace, when the god-engineer dictated the mechanists philosophy of the Universe. The universe-machine created the man-robot that started to be the Man to be understood. Laplace's words are significantly tendentious towards it:

"An intelligence that in a given moment knows all the forces that animate Nature, and the respective situation of beings that compose it, and if in addition, this intelligence were wide enough to submit data to analysis, it would encompass similarly the movement of the largest bodies of the Universe and the lightest atoms of all: nothing would be uncertain for it and both the past and the future would be present..."

Many times we face reports of people capable of reading between the lines about the facts of nature: people from the country who can predict rain, fishermen who can identify storms, and even popular readers of social, political and economic movements on TV screens. Our daily News on TV are an example of our urge for fortune tellers that do not have religious or spiritual bias, but rather project their views based on the secular appeal of personal experience. All of them, for some reason, are attentive to signs, not always orthodox or habitual, but somewhat they seem to have some precise or safe link with future events.

In our clinical practice, in the search for clues that can guide our steps, we look for reliable information that represents the status of the patient who comes to us. This task is based on the knowledge that experience, supported by pathophysiologic concepts, can have an unmistakable meaning and brings safe responses to each of the problems. Experience, concepts and data collection are the driving forces of the specialist. For data collection, we have a wide range of options. Among them the instrument measurements, which have evolved since the astrolabe and the telescope and that reached its peak by being able to look inside the human body to try to identify molecular relations. Today we can visualize neural electrical waves that teach us how hearing sound waves move inside us, follow the distribution of hemoglobin through the parenchyma organs, measure the amount of this or that substance that is accumulated in one or other body region, perceive minute vibrations of the vocal fold mucosa when speaking, and who knows what else? All these possibilities are controlled by the knowledge of anatomophysiology that the specialist has and are powerful tools to recover and maintain health status.

Said that, it is worth understanding how a specialist operates right now. Bachelar, in a very witty interview to Le Monde years ago, when asked whether his philosophical experience provided enough information to design the human nature, answered that he imagined the philosopher like a three-floor house: the family floor, in which most everyday tasks were performed and that expressed the common aspect of the owner; the basement, where the tools and instruments for the most modifying and entrepreneurial activities were kept, rarely seen in the daily routine, and finally, the attic, where all memories, secret desires and expectations were kept, and that only the owner could access in his moments of introspection. It is your image in the mirror, constructed in small memory fragments.

By facing the specialty in the same fashion, we can clearly see that the family floor will always be the busiest one, and the other two will be reserved for specific activities, but not less important, which are in fact essential to comprise a harmonious aspect of a family house. The issue of scientific instrumentalism and various therapeutic techniques and their consequences and repercussions for Health Sciences can be analyzed under the concept of the three-floor house.

When reading the ideas of Damazio we start to reflect about the topic from a less universal standpoint and end up in a philosophical dilemma: can the needle that marks the electrocardiogram understand the electrical heart activity? In the words by Damazio, "It does not matter whether experimented or observed, pathos is the sub-product of the conscience, similar to desire". To him, everything depends on the experience and, therefore, the awareness of the observed or the observer. Man becomes present and the instrument is not a tool that objectively works its will. In fact, many times the instrument can make the will and express the subjectivity of the creator. In Ancient Greece, Protagoras insisted that "Man is the measure of all things", defining the principles of humanism and relativism. We do not want to overemphasize the role of subjectivism in clinical investigation or diagnosis, but only protest informally against the dictatorship imposed by the results of instrumental measurement in lieu of clinical impression.

When it comes to conclude how much was invested in health and how far we went, we realize that the Scientific Revolution that led to positivism offered us an enormous and magnificent capacity to compile organic data, quantifying our actions and internal economy. However, it has proved to be fragile in capturing most of the aspects that represent the human "being". Koyre, in his Etudes newtoniennes, referred to positivism by saying, "The modern science has done it by replacing our world of sensitive qualities and perceptions, the world in which we live, love and die, for another world of quantity, deified geometry, a world in which although there is room for everything, there is no room for mankind. Thus, the world of science, the real world - is farther and completely separated from the living world that science was incapable of explaining - even a dissolving explanation that could create a subjective appearance (...)". This is the modern spirit tragedy that "solves the enigma of the universe, but only to replace it by another one: the enigma of themselves". Serres, in the "Legend of the Angels", commented the role of the middle person in the traffic of information. I think his comments were pertinent in view of the fact that we want to understand the real role of instruments and measurements of human attributes through machines. In his reflection about the middle person, he uses the metaphor of the leaded-glass window:

"Humble, loyal, the window lets the day rays pass.. or the design, the colors, the beauty of the leaded-glass change, like a prism, the white sun light in the spectrum exposed to its secret composition. The theme addressed in the leaded-glass window evokes the same issue of the middle person: brilliant, it may intercept the message; discreet, it prevents it from being heard. Should it appear or disappear?"

All instrument has a tutor, a creator, with points of view, beliefs and personal concepts. To what extent an instrument serves as a window? How much of the message originated from a studied subject comes from him, and how much of the information is generated or obstructed by the instrumental mechanism? Serres comments also, "the representative may appear to be the authority that has vested its power". Would the instrument be the message of the observed or of the creator/observer?

Looking back, we are taken aback. Rational positivism, which generates and creates our safety in scientific objectivity, turns out to be filled with subjectivity hidden behind screws and bolts, and since they are rarely questioned, they become absolutist dogmas. This is the key fact. The figure of the specialist should have the reference role of interpreting data. We live through a moment in which many use information, but few can account for the offered clinical pictures. As a symbolic example, we can mention the situation of Otorhinolaryngology and Head and Neck Surgery. Two specialties defined in our environment. One that has been formally in practice for about 100 years, another whose first professional training programs were opened about one decade ago. Otorhinolaryngology has approximately 5,500 specialists in Brazil, whereas Head and neck has about 500. There are more than 80 programs of ENT training and not more than 20 in Head and neck surgery. Both have an anatomic region as focus. What logic argument would make medicine have two specialties with the same scope? Both have the same anatomophysiology grounding, make use of the same data collection instruments and represent similar clinical and surgical therapeutic projects. What differentiates them? In my opinion, only the fact that one deals exclusively with oncological entities. Is that justification enough to bring into existence a specialty? As if Endocrinology did not treat diabetes, leaving it to another specialty, or if Ophthalmology did not operate on cataracts. It is the time to rethink the design of our specialty, assuming that some can deal only with major surgeries and therapeutic planning of ENT oncological affections, similarly to other divisions of the specialty, such as Otoneurology, hosting the specialists of Head and neck surgery into the mother ship of ENT, so as to continue to invest in the training of an open-minded specialist that could provide to the patients, our patients, everything they needed. It is paramount that measurement and technique per se do not overrule the whole. The three-floor house should be preserved and the use of instruments, techniques (the basement) and traditions (the attic) should be understood as part of a greater whole (the house).

Dear readers, it was only a bit of meditation amidst so much scientific thinking. I would like to apologize for using a privileged space to express my personal opinions.

Nevertheless, the floor is opened for discussion...

Regards,

References

Damazio, A . The feeling of what happens. Ed. Verlag, Nova Yorque, 1999.
Dupuy, J. Na origem das ciências cognitivas. Ed. Unesp, São Paulo, 1994.
Fourez, G. A construção das ciências. Ed. Unesp, São Paulo, 1996.
Jupiassu, H. A paixão da ciência. Ed. Letras e Letras, São Paulo, 1999.
Horgan, J. O fim das ciências. Companhia das letras, São Paulo, 1998.
Morin, E. O método. A natureza da Natureza. P. Europa-América, São Paulo, 1987.
Prigogine, Y. A nova aliança. Ed. UNB, Brasília, 1997.
Ruelle, D. O acaso e caos. Ed. Unesp, São Paulo, 1993.
Serres, M. A lenda dos anjos. Ed. Aleph, São Paulo, 1995.

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