(by Stefania Capogna) The Digital Conference promoted by the DiTES (Digital Technologies, Education & Society) and DASIC (Digital Administration and Social Innovation Center) research centers of Link Campus University took place on 25 June 2020, in collaboration with AIDR ( Italian Digital Revolution Association) to reflect in a multidisciplinary and multi-perspective key on the "complex doctor-patient relationship" that new technologies are able to influence and transform.
The starting point of the Round Table was the impact of the global pandemic on medical practice that faced in the emergency - as never before - with a necessary and massive use of Information and Communication Technologies to guarantee the distancing and containing the spread of the infection, continuing to offer assistance, care and comfort. From on-line diagnoses, to the recipe for whastapp, to the delivery of the analysis results via e-mail, all these practices, which already existed before Covid-19, have imposed themselves showing the possibility and need to think about a new structure socio-health care in the light of the social transformations that characterize our days.
The panel of scholars, experts, doctors and researchers discussed these issues allowing them to analyze the issue from different perspectives.
The professor. Greco, of Link Campus University, focused on the usefulness of redefining the concept of 'physical distancing' in place of the initial tendency to speak of 'social distancing', emphasizing that technologies have represented a valid support for the configuration of new forms of socializing and reducing distances, in a time of serious social unease.
The global pandemic has imposed, as points out, prof. Corposanto (Magna Graecia University) a new 'spatiality' and a different 'temporality, bringing to light some “polarizations” on which it is necessary to reflect. In the first place, it refers to the diversity with which the virus has struck on a global scale, going to weigh in an unequivocally more dramatic way in the poorest countries and communities. Secondly, there has been a sort of perceptual alteration of temporality that sees at an extreme the high pace of work of all medical health professionals, who have found themselves facing the emergency in a scenario of war, and to another extreme is the expansion of a timeless time that the quarantined population has experienced. But the question of time also calls into question the contrast between "the slowness through which the relationship between patient and general practitioner is built", a relationship of proximity that leads the doctor to know not only the patient's clinical history but also his life, its habits, the social and cultural fabric in which it is inserted, and the speed of digital diagnostics; a precious ally but unable to build an empathic relationship.
It is also clear that the virus has highlighted differences related to socio-economic status, age, gender, going to hit more strongly in the territories that over the years have known the impoverishment of the territorial protection and assistance network, marked the reduction in the number of general practitioners who have proven to be the first significant interface for controlling the virus. "In the territories with fewer general practitioners, in a perverse reverse relationship, there has been more devastation from Covid." The pandemic has in fact highlighted the close connection between biophysical and bio-social aspects of the disease, which contribute to the spread of the virus in the context of an increasingly globalized world.
Another important contrast is that between "expert knowledge and widespread knowledge" which has made the problem of communication and scientific information necessary to counter the spread of fake news and reduce the risk of abuse and scams of all kinds.
Andrea Bisciglia (Clinical cardiologist and interventionist at the San Filippo Neri Hospital Complex in Rome and Head of the AIDR Digital Health Observatory) identifies three key points in the doctor-patient relationship: empathy, harmony and sympathy. In the practice of the medical profession we are confronted with different types of stress that ask the doctor for different skills and attitudes. Some doctor / patient interactions do not involve interaction, such as an operating room where an intervention is made on a sleeping patient, and where it is necessary to keep steady nerves and coolness. In all situations where there is interaction, it is necessary to establish "a dynamic and always different interlocutory relationship that cannot be found in the guidelines and health protocols," because each person is different and bearer of specific requests. And sometimes it is more difficult to talk and listen than to operate. In addition, the pandemic has brought telemedicine to the scene, which in reality was already present and used, but in the Covid-19 scenario 63% of doctors were forced to use it. And this has led to a general acceleration that starts from the opportunities opened up by digital, to directly invest the sphere of the doctor-patient relationship. However, it is clear that telemedicine cannot replace the care relationship. It can be a useful ally to favor precision diagnosis, for the monitoring of chronic diseases, to allow remote interventions / assistance, for the timeliness of the intervention but it is not self-resolving. Today patients are on average more informed and more demanding, they have often already consulted the network and have a self-diagnosis and a hypothetical cure; they want to heal quickly. Establishing a relationship of trust with these conditions is very difficult. The challenge therefore is to enrich the doctor-patient relationship with the new opportunities that interactions mediated and / or supported by technologies can offer, guaranteeing the right space for the recognition of the specificities each bears in his or her historical, cultural and biographical experience.
The challenge of telemedicine and of all e-health shifts reflection to the issue of correct data management and device safety. Giustozzi (cyber security expert of CERT-AGID) underlines that in this phase of emergency only critical situations have been amplified that were already under our eyes without our having sufficient and widespread awareness. The Internet was designed and tested in a time when the subject of data did not exist, nor was it imaginable that an economy and a data market would develop within a few decades. Today, therefore, an attempt is being made to “correct the initial system, with all the criticalities that involve intervening on an old system with new measures”. However, if on the one hand we try to remedy the existing technology with other technology, there is a serious and widespread gap connected to the lack of awareness on its careful and responsible use, sometimes accompanied by a serious attempt to deny or underestimate the problem. in decision making. Only a widespread digital culture can shelter from those dark sides and protect the community from the drift of technophobic and obscurantist reactions, fueled by a scarce scientific and technological culture. Reactions therefore fueled by fear and rejection of what is not known and not governed, "fueled by ignorance". That is, from ignoring the basic assumptions and functioning of technology.
A positive note comes from Dr. Alimenti (DASIC) who shares the experience of co-designing the digital Apps for the treatment and how this reshapes the doctor-patient relationship, underlining how essential is a multidisciplinary approach for the creation of e-health technologies, such as chat boxes for communication management; the design of interfaces to study the patient's stimuli, involvement and emotional condition and thus provide targeted and timely responses for fragile, chronic or disabled people.
While everyone agrees that telemedicine and digital technologies can provide valuable help in emergencies, everyone is equally aware that no technological surrogate can ever replace the doctor-patient relationship. This does not exclude that it is essential to invest in order to ensure that these devices can assist and support medical and health care in a renewed relationship capable of putting the patient at the center.
In an attempt to trace the common thread of these testimonies, the reflection shifts to another order of considerations.
First of all, a crisis of credibility in science and technology is recognized, or rather a cultural crisis of modernity that has centered its social model on triumph and an excess of trust in science and technology. Over time this has produced a communication short circuit, accompanied by an effect of de-responsibility of both politics and science. At the same time, we are helplessly witnessing the crisis of traditional knowledge transmission belts, when the school fails to transmit the value and epistemology of science; while the community is enveloped in a culture of health that appears trapped on the one hand by the hospitalization model and on the other by a pressing logic of consumption. The sum of all these factors has led over time to the dramatic impoverishment of communities and territories in the transfer of that 'foreknowledge' made up of traditions, rituals and social and cultural habits on which the social architecture of daily life is based, helping to loosen the space-time pre-condition in which the care relationship develops. A relationship in which the doctor is not only the one who treats but helps to educate the subject in a logic of empowerment and taking charge of the health of his patients.
The relationship with science and technology is on another level. There is a sort of detachment from the promises that this can offer. Perhaps we must have the honesty to say that we tend to ask wrong questions and requests to these two dimensions of social life, thinking that they can save humanity from its condition of finitude, defeating death, suffering, injustice and any form of abuse.
Asking the right questions means directing expectations and therefore priorities also for investments which, by definition, are scarce. To what extent does it make sense to invest in the development of scientific and technological discoveries that remove death from our sight and our experience, feeding the illusion of immortality. When it is known that the greatest advances in the conditions and quality of life that humanity has known during the twentieth century (to the benefit of a small portion of the global population) are mostly derived from the improvement of hygienic conditions. health and cultural.
In summing up this reasoning, some problematic issues emerge which must be duly taken into account in planning the return to new normality for what is called society 5.0. A society characterized by the radical transformation of the fabric and social spaces determined by:
- the swirling development of megalopolises, where increasing shares of population are concentrated, leaving the territories, and which are often characterized by large sections of poverty, concentrated in the suburbs and / or in the urban interstices;
- a strong aging of the population, particularly in the richer societies, where the lowering of the birth rate is accompanied by the renunciation of both parenting and the building of long-term emotional relationships;
- the pervasiveness of technology that invades every area of our life, going beyond our own capacity for action and control;
- a significant crisis of sustainability of essential services, now considered acquired rights, such as the right to life, which often results in the search for eternity through persistent therapy and intensive care; the right to care, which translates into the removal of all suffering and pain, with a drift towards the "pornography of death"; the right to assistance, which sometimes leads to the delegation of responsibility and self-direction and / or the search for the scapegoat.
The global pandemic has clearly highlighted the fragility of this system.
To bring the reasoning back to the focus of this round table that has tried to question itself on how to accompany an improvement in the complex doctor-patient relationship, two important emergencies can be glimpsed that arise at different levels.
The first concerns the training of health professions. The second involves a system dimension.
As regards the theme of the formation of health professions for the XNUMXst century, two emerging macro-areas of competence are outlined. On the one hand, it is becoming increasingly urgent to invest in 'doctor-patient communication' to help the care professional to build that pact of trust that in globalized, multi-ethnic societies oriented towards discrediting science and expert knowledge is preliminary to the treatment itself. . But the problem remains of how to cultivate the sensitivity and the ability of an authentic and empathic listening which is by no means obvious and never automatic and transcends mere technical competence. In fact, it is possible to know all the theories of the world and not know them, and not be able to act them when one is close to the pain of the other or in stressful conditions or in organizational environments that do not support the culture of the quality of relationships. On the other hand, it is essential to put the enhancement of digital skills at the center so that this wide range of devices can be integrated and enhanced in professional practice, without running the risk of dehumanizing the relationship. Also in consideration of the fact that communication mediated by digital technologies amplifies the risk of misunderstanding and conflict.
William Osler asserts that “there are two types of doctors, those who practice with the language and those who practice with the brain” to underline the distance between the rational and relational dimensions. I like to think that a care professional must be able to exercise with the brain, with the language (i.e. the word) and with the heart, so that he can put together these three dimensions of personal and professional action. And this is a new challenge both for universities, which are committed to training new professionals in the medical-health area, and for professional bodies to ensure the personal and professional support and growth of these figures throughout their lives.
As regards the system dimension, it is necessary to strategically rethink the doctor-patient relationship in the context of the transformations taking place. Rethinking the care relationship, with and without the aid of new technologies, recalls the need to reinvent and re-design this relationship within an organizational system and a socio-health and hospital system capable of de-institutionalizing and de-hospitalization illness, chronicity, fragility, through the construction of new forms of alliance and relationships in the territories, aimed at intercepting, recognizing and enhancing the social space in which the patient moves, to transform this space into a value and an ally of care . It is evident that this transcends the theme of the doctor-patient relationship and directly affects the idea of which vision and model of care and care, of the center-periphery relationship and of alliance in the territories it intends to pursue. Much more than a problem of medical professionalism but a health policy problem that would require far-sighted visions and participation at all levels.
Stephanie Capogna - Associate Professor and Director of the Research Center Digital Technologies, Education & Society, Link Campus University and Head of AIDR Digital Education Observatory