Abstract

Introduction

The Family and Community Medicine movement (FCM) has as one of its proposals within the guiding principles of the specialty, the valorization and strengthening of the doctor-patient relationship¹McWhinney IR, Freeman T. Textbook of family medicine. New York: Oxford University Press; 2009.. For this purpose, the proposal of a Person-Centered Clinical Method (PCCM) is highlighted, placing the interaction between doctor and patient as a central focus, taking into consideration the particularities of those involved as well as allowing the patient to have a leading role in this relationship²Stewart M, Brown JB, Weston WW, McWhinney IR, McWilliam CL, Freeman TR. Medicina centrada na pessoa: transformando o método clínico. 3a ed. Porto Alegre: Artmed; 2017.. As proposed by McWhinney¹McWhinney IR, Freeman T. Textbook of family medicine. New York: Oxford University Press; 2009., the family doctor should aim to know the person before getting to know the disease, which means that it is necessary to make use of resources usually used in interpersonal relationships, with their subjective and immeasurable aspects, such as intuition, empathy, one’s emotions and those of the other. For the purposes of this article, we will call these relational technologies as “light technologies”, as presented below³Merhy EE. O ato de cuidar: a alma dos serviços de saúde. In: Brasil. Ministério da Saúde. Secretaria de Gestão do Trabalho e Educação na Saúde. Departamento de Gestão da Educação na Saúde. Ver-SUS Brasil: caderno de textos. Brasília: Ministério da Saúde; 2004. p. 108-37.,⁴Merhy EE. O cuidado é um acontecimento e não um ato. Trabalho, produção do cuidado e subjetividade em saúde: textos reunidos. São Paulo: Hucitec; 2013..

The longitudinal character of the care that the doctor offers at individual, family and community level is of great importance in building the relationship between family doctor and user. Longitudinality is defined as the subject follow-up over time for diagnostic, therapeutic and preventive purposes, and is one of the essential attributes of Primary Health Care (PHC)⁵Starfield B. Atenção primária: equilíbrio entre necessidades de saúde, serviços e tecnologia. Brasília: Unesco, Ministério da Saúde; 2002.. This continuous follow-up allows multiple encounters between doctors and users, generating opportunities to deepen the understanding of the subject’s characteristics, therefore understanding that a person’s numerous illnesses only make sense when recognized in his/her personal, family and community context⁶Campos CEA. Os princípios da Medicina de Família e Comunidade. Rev APS. 2005; 8(2):181-90.. And, more than this, it is capable of producing a bond - a connection - between family doctor and user, a bond that emerges and is maintained in the interaction that happens in each encounter between these actors, generating diverse feelings in both, and strengthening the connection between them⁶Campos CEA. Os princípios da Medicina de Família e Comunidade. Rev APS. 2005; 8(2):181-90.,⁷Seixas CT, Baduy RS, Cruz KT, Bortoletto MSS, Slomp Junior H, Merhy EE. O vínculo como potência para a produção do cuidado em saúde: o que usuários-guia nos ensinam. Interface (Botucatu). 2019; 23:e170627..

The concept of bond appears in documents related to Primary Care in Brazil as an instrument operating upon the coexistence among the subjects and with potential to confront health issues and keeping people healthy⁸Brasil. Ministério da Saúde. Saúde da Família: uma estratégia para a reorientação do modelo assistencial. Brasília: Ministério da Saúde; 1997.,⁹Brasil. Ministério da Saúde. Portaria nº 2.488, de 21 de Outubro de 2011. Aprova a Política Nacional de Atenção Básica, estabelecendo a revisão de diretrizes e normas para a organização da Atenção Básica, para a Estratégia Saúde da Família (ESF) e o Programa de Agentes Comunitários de Saúde (PACS). Brasília: Ministério da Saúde; 2011.. It is also understood as an essential factor in building relationships of trust and closeness between users and health workers, stimulating co-responsibility and intensifying the therapeutic potential of health encounters¹⁰Franco TB, Bueno WS, Merhy EE. O acolhimento e os processos de trabalho em saúde: o caso de Betim, Minas Gerais, Brasil. Cad Saude Publica. 1999; 15(2):345-53.. In a review¹¹Brunello MEF, Ponce MAZ, Assis EG, Andrade RLP, Scatena LM, Palha PF. O vínculo na atenção à saúde: revisão sistematizada na literatura, Brasil (1998-2007). Acta Paul Enferm. 2010; 23(1):131-5. with regards to bonding in health care in Brazil, it is depicted the deepening of the understanding of the population’s health problems, attended by the professionals linked to them, which would motivate them to develop a joint effort in search of solutions, facilitating the relationship between users and professionals.

Regarding the encounter between doctors and users, the contact between these actors in the health production proposal may constitute an intercessor meeting, in the sense of allowing the emergence of a singular process, a product that is done in act, an intercessor space that will only exist in these meetings³Merhy EE. O ato de cuidar: a alma dos serviços de saúde. In: Brasil. Ministério da Saúde. Secretaria de Gestão do Trabalho e Educação na Saúde. Departamento de Gestão da Educação na Saúde. Ver-SUS Brasil: caderno de textos. Brasília: Ministério da Saúde; 2004. p. 108-37.,⁴Merhy EE. O cuidado é um acontecimento e não um ato. Trabalho, produção do cuidado e subjetividade em saúde: textos reunidos. São Paulo: Hucitec; 2013.. In Merhy’s words⁴Merhy EE. O cuidado é um acontecimento e não um ato. Trabalho, produção do cuidado e subjetividade em saúde: textos reunidos. São Paulo: Hucitec; 2013.:

In this field, the technological dimensions of care may be operated through hard, and light technologies, but especially the latter³Merhy EE. O ato de cuidar: a alma dos serviços de saúde. In: Brasil. Ministério da Saúde. Secretaria de Gestão do Trabalho e Educação na Saúde. Departamento de Gestão da Educação na Saúde. Ver-SUS Brasil: caderno de textos. Brasília: Ministério da Saúde; 2004. p. 108-37.,⁴Merhy EE. O cuidado é um acontecimento e não um ato. Trabalho, produção do cuidado e subjetividade em saúde: textos reunidos. São Paulo: Hucitec; 2013.. Hard and light-hard technologies constitute the hegemonic modalities, which include professional-centered actions through more invasive interventions, dependent on equipment and material resources (hard technologies), or specialized knowledge and strictly protocolized interventions (light-hard). Light technologies are the technologies of relationships, and can be exemplified by the production of bonds, stimulation of autonomy, embracement and management as a way of organizing work processes in the sense of producing care. In their proposal, they bring a collective way of building configurations of care with user-centered health care, and consequent shared construction of care³Merhy EE. O ato de cuidar: a alma dos serviços de saúde. In: Brasil. Ministério da Saúde. Secretaria de Gestão do Trabalho e Educação na Saúde. Departamento de Gestão da Educação na Saúde. Ver-SUS Brasil: caderno de textos. Brasília: Ministério da Saúde; 2004. p. 108-37.,⁴Merhy EE. O cuidado é um acontecimento e não um ato. Trabalho, produção do cuidado e subjetividade em saúde: textos reunidos. São Paulo: Hucitec; 2013..

Most studies on the quantitative aspects of the physician-user relationship in the context of PHC show an increase in the satisfaction of users who are accompanied longitudinally by a reference family doctor¹²Mainous AG, Baker R, Love MM, Gray DP, Gill JM. Continuity of care and trust in one’s physician: evidence from primary care in the United States and the United Kingdom. Fam Med. 2001; 33(1):22-7.

Caprara A, Rodrigues JV. A relação assimétrica médico paciente: repensando o vínculo terapêutico. Cienc Saude Colet. 2004; 9(1):139-46.-¹⁴Sans-Corrales M, Pujol-Ribera E, Gene-Badia J, Pasarin-Rua MI, Iglesias-Perez B, Casajuana-Brunet J. Family medicine attributes related to satisfaction, health and costs. Fam Pract. 2006; 23(3):308-16.. Additionally, it has been described that the bond and continuity in the follow-up of users can produce in the family doctor a higher sense of responsibility for those people and professional satisfaction, while other studies also show feelings such as the strengthening of the sense of competence, but also emotional wear and tear due to difficulties in diagnosis and the relationship with demanding users, which can lead to psychological exhaustion and even burnout syndrome¹⁵Frederiksen HB, Kragstrup J, Dehlholm-Lambertsen G. It’s all about recognition! Qualitative study of the value of interpersonal continuity in general practice. BMC Fam Pract. 2009; 10:47.,¹⁶Schultz K, Delva D, Kerr J. Emotional effects of continuity of care on family physicians and the therapeutic relationship. Can Fam Physician. 2012;58(2):178-85..

Over a half of the physicians suffer or have suffered from symptoms related to professional exhaustion, and in family doctors the prevalence can reach 60%¹⁷Ramirez AJ, Graham J, Richards MA, Cull A, Gregory WM. Mental health of hospital consultants: the effects of stress and satisfaction at work. Lancet. 1996; 347(9003):724-8.,¹⁸Puffer JC, Knight HC, O’Neill TR, Rassolian M, Bazemore AW, Peterson LE. Prevalence of burnout in board certified family physicians. J Am Board Fam Med. 2017; 30(2):125-6.. Among the main factors that trigger or aggravate this burnout in doctors, are worth of note the following: the inadequacies of work processes; overload; limitations and ambiguity in the performance of roles; emotionally fraught consultations, among others¹⁹Visser MR, Smets EM, Oort FJ, De Haes HC. Stress, satisfaction and burnout among Dutch medical specialists. CMAJ. 2003; 168(3):271-5.. On the other hand, factors such as a good relationship with users and feeling recognized and valued for their work are related to the feeling of professional satisfaction, and therefore can protect the doctor against the physical and psychological effects of long-term stress. Moreover, when stress takes precedence over professional satisfaction, the risk of exhaustion is considerably increased¹⁷Ramirez AJ, Graham J, Richards MA, Cull A, Gregory WM. Mental health of hospital consultants: the effects of stress and satisfaction at work. Lancet. 1996; 347(9003):724-8.,¹⁹Visser MR, Smets EM, Oort FJ, De Haes HC. Stress, satisfaction and burnout among Dutch medical specialists. CMAJ. 2003; 168(3):271-5.. What, then, would be the role of bonding in producing stressful or rewarding feelings for family doctors experiencing a longitudinal relationship of care for their users? Would the bond itself be a factor in the generation of overload, as the doctor intensifies the relationship with the user and feels responsible for the person’s health outcomes? Or could the therapeutic and satisfying potential that the bond has for the user be extrapolated to the doctor as well?

This research, linked to the Family Health Professional Master’s Program (ProfSaúde), promoted by the Brazilian Association of Collective Health (ABRASCO) and Brazilian teaching and research institutions, aimed to understand the effects that bonding and responsibility between family doctors and users can produce on doctors themselves. Its constructive process was conducted from the perspective of the micro-politics of care and work in health. Throughout the fieldwork, an opening was made to new issues pointed out by the empirical findings (such as, for example, the existence of a medical identity territory and the possibilities of restructuring this territory from the experiences allowed by the bond with the user). This dynamic character of the study was in conformity with the methodological strategy chosen, the cartographic approach, which allows the researchers to be immersed in the field of research therefore producing knowledge through the affections and intercessions brought about by the encounter between researcher and researcher²⁰Kastrup V. O funcionamento da atenção no trabalho do cartógrafo. Psicol Soc. 2007; 19(1):15-22.,²¹Passos E, Kastrup V, Escóssia L. Pistas do método da cartografia: pesquisa intervenção e produção de subjetividade. 4a ed. Porto Alegre: Sulina; 2015..

Methodology

It is an exploratory study with a qualitative approach and cartographic orientation. Ten open interviews with trigger questions (Frame 1) were conducted with family physicians working at PHC in Curitiba, state of Paraná and doctors undergoing the FCM residence at the Federal University of Paraná (UFPR) who had been working for a year or more in the same community, to ensure a minimum degree of longitudinality required for the development of the study. The choice of participants was made by appointment among professionals from these institutions, with an individual invitation made by the researchers, intentionally choosing those professionals who were described by their peers as having a close relationship with their users and community. Physicians from three different groups were interviewed, according to the criteria of time spent working in PHC: I) Residents with two or three years of FCM practice; II) young physicians with up to 15 years of work in PHC; and III) experienced physicians with more than 30 years of professional activity. Such classification of participants was considered in the research as necessary for an evaluation dependent on some degree of longitudinality, and allowed access to different opinions and experiences.

The interviews took place between January and October 2018, after obtaining informed consent from the participants. They were conducted individually (a researcher interviewed a participant at each meeting), in environments chosen by the participants, where confidentiality and privacy of information could be guaranteed (for example: participant’s office, University meeting room, participant’s residence). The material obtained in the interviews was analyzed by the researchers from the perspective of the cartographic approach, which proposes to value processes of subjectivation in the field of research, allowing for the collection of information no longer to be restricted to the domain of representation, therefore allowing for an analysis procedure in which reality is to be studied in constant transformation and movement, a reality composed of different narratives, contexts and lines of force to be considered in its complexity and uniqueness²⁰Kastrup V. O funcionamento da atenção no trabalho do cartógrafo. Psicol Soc. 2007; 19(1):15-22.,²¹Passos E, Kastrup V, Escóssia L. Pistas do método da cartografia: pesquisa intervenção e produção de subjetividade. 4a ed. Porto Alegre: Sulina; 2015.. Based on the reference of micropolitics, we sought to access the experiences the way they were lived by the participants, and in the intercessor encounters between researchers and interviewees we sought to allow different possibilities of subjectivation and singularization, in addition to exchanging knowledge, and doing so in a process that included the pedagogical dimension²²Guattari F, Rolnik S. Micropolítica: cartografias do desejo. Petrópolis: Editora Vozes; 2000.. In this manner, it became possible to map not only the subjectivity of the other, but also affections and mutual transformations, including those of the researchers, and the product of this cartography was extensively recorded in field diaries.

During the progress of the research, some preliminary analyses of the empirical material showed, as we will see in the next section, a codification defined by a certain “medical being”, demanding the use of another concept and tool of the micropolitics reference frame: the “identity or existential territory”²³Deleuze G, Guattari F. Mil platôs – capitalismo e esquizofrenia. Rio de Janeiro: Editora 34; 1995. (Coleção Trans(2) ).,²⁴Guattari F. Caosmose: um novo paradigma estético. São Paulo: Editora 34; 1992. (Coleção Trans).. This concept had already been used in previous research²⁵Slomp Junior H, Feuerwerker LCM, Land MGP. Educação em saúde ou projeto terapêutico compartilhado? O cuidado extravasa a dimensão pedagógica. Cienc Saude Colet. 2015; 20(2):537-46. to understand how historical-social repetitions of discursive sets produce a normative body for acting/living, sets that are composed of significant referents (in that research “to be a health professional”) and transcendent values (in this research “how the health professional should be and act”)²³Deleuze G, Guattari F. Mil platôs – capitalismo e esquizofrenia. Rio de Janeiro: Editora 34; 1995. (Coleção Trans(2) ).,²⁴Guattari F. Caosmose: um novo paradigma estético. São Paulo: Editora 34; 1992. (Coleção Trans).. The concept of existential identity or self-referenced territory is based on the assumption that the significance of communication, not dissociating expression and content, is involved in processes of subjectivation²³Deleuze G, Guattari F. Mil platôs – capitalismo e esquizofrenia. Rio de Janeiro: Editora 34; 1995. (Coleção Trans(2) ).

Guattari F. Caosmose: um novo paradigma estético. São Paulo: Editora 34; 1992. (Coleção Trans).-²⁵Slomp Junior H, Feuerwerker LCM, Land MGP. Educação em saúde ou projeto terapêutico compartilhado? O cuidado extravasa a dimensão pedagógica. Cienc Saude Colet. 2015; 20(2):537-46..

If speaking about an identity, or acting according to it brings it to existence, the de-constitution of this identity territory can also happen through “deterritorializations”, or exits to other meanings, totally or partially changing the limits of the current identity in the sense of new “re-territorializations”²⁴Guattari F. Caosmose: um novo paradigma estético. São Paulo: Editora 34; 1992. (Coleção Trans).. It should be added that the principal researcher/author is a family and community doctor, in full professional activity during the course of her research field work, and that, since she is undergoing studies to obtain a professional master’s degree, she experienced by herself the daily situations and feelings very similar to those she was investigating.

This study was approved by the Research Ethics Committee (CAAE nº78685517.3.0000.0102).

Results and discussion

Ten physicians were interviewed, four of them resident physicians (MR) up to 29 years old; three “young physicians” (MJ) aged between 31 and 37 years; and three experienced physicians (ME) aged between 55 and 62 years. There were four women and six men, having completed their medical training in periods ranging from 2 to 36 years, and working in the health unit during periods from 1 to 18 years. The main researcher, when interviewing colleagues from specialty and work scenarios, although she was not herself interviewed, placed herself at the same time as researcher and research-participant in matters referring to the present analyses, in an inter-place that the cartographic approach allowed her, since “being a doctor” is an existential identity that also constitutes her as a subject.

All the interviewees brought in their statements elements that we relate to a “medical identity territory” or “medical identity”, a set of statements that offer normative values and convictions of behavior whose daily repetition legitimizes their actions as professionals when structuring a belonging to this profession. As examples, we identify expressions such as “the scope of medicine”, “bread and butter of doing medicine”, “being a doctor”, as some of the following passages show:

The above statements show that the idea of “being a doctor” presupposes a certain code that is concretized in the territory from which the doctors speak and in which they understand themselves: everything that extrapolates such limits would configure a “beyond being a doctor”. Possibly, even before the medical graduation, subjects already carry within themselves the elements that compose such territory, from their life history, culture, beliefs, lived experiences, which orbit around the theme “medicine”²⁶Pessotti I. A formação humanística do médico. Medicina (Ribeirão Preto). 1996; 29(4):440-8.,²⁷Ramos-Cerqueira ATA, Lima MCP. A formação da identidade do médico: implicações para o ensino de graduação em Medicina. Interface (Botucatu). 2002; 6(11):107-16.. The medical identity, therefore, is a construction that is not exclusive to the university education of this professional.

The constitution of what a “medical identity” would be, is expressed in these statements showing that, for the totality of the interviewees, there is an assumption that to exercise this profession it would be necessary to follow a certain way of acting, of being, of thinking. Such concepts bring elements that go back to the origins of medicine, as can be seen, for example, in the philosophy of Avicena, a Persian physician of the Middle Ages who enumerated the many aptitudes expected of those who practiced medicine, such as:

It is in the Middle Ages that “being a doctor” started to be defined in the social context, with the exercise of medicine beginning to be regulated by laws and the need to grant a degree²⁸Hoirisch A. Ser médico, implicações históricas e antropológicas. São Paulo: Casa do Psicólogo; 2006.. From that moment on, the figure of the physician has a greater social expression, since the physician bases his practice on methods and techniques based on scientific knowledge that “belongs” to medicine²⁸Hoirisch A. Ser médico, implicações históricas e antropológicas. São Paulo: Casa do Psicólogo; 2006.. The idea of the omnipotent, altruistic doctor, with power over life and death, is moving towards a pronounced idealization of the profession²⁶Pessotti I. A formação humanística do médico. Medicina (Ribeirão Preto). 1996; 29(4):440-8.

Ramos-Cerqueira ATA, Lima MCP. A formação da identidade do médico: implicações para o ensino de graduação em Medicina. Interface (Botucatu). 2002; 6(11):107-16.-²⁸Hoirisch A. Ser médico, implicações históricas e antropológicas. São Paulo: Casa do Psicólogo; 2006.. In this sense, most of those interviewed interpret their actions as an exercise of their power as doctors, and recognize that there is a feeling of omnipotence that permeates their professional practice, whether by the attitude of the doctors themselves towards their users, or by the attitude of society or institutions towards the doctor:

Jeammet et al.²⁹Jeammet P, Reynaud M, Consoli S. Manual de psicologia médica. Rio de Janeiro: Medsi; 2000. quote aspects of the power relationship between doctors and users, where the former is in a position of “enlightened authority” because she/he is the bearer of knowledge for healing. Maldonado³⁰Maldonado MTP. A ilusão de onipotência na relação médico-cliente. Cienc Consciencia. 1978: 324-31. comments regarding the belief that the professionals will only be worthy of respect and trust if they place themselves as strong and omnipotent persons and, more than this, that there would be a desire on the part of doctors to create an aura of mystery about their procedures, adopting an authoritarian conduct with fewer possibilities for questioning. If, on the contrary there is an approach, a caring attitude, then, “it doesn’t even seem like she’s a doctor”, as ME3 quotes.

The idea of omnipotence that is intrinsic to the doctors’ identity territory will not only reflect in their power relations with other subjects, but also in the way doctors see themselves, how they experience feelings such as fear of making a mistake, guilt for a presumed failure, shame for not meeting expectations, or even difficulty in remaining emotionally intact so as not to prove fragile in front of the other, and commit their judgments in face of decisions to be made³¹Da Silva ALP, Teixeira MAA. A angústia médica: reflexões acerca do sofrimento de quem cura. Cogitare Enferm. 2002; 7(1):75-83..

The Code of Hammurabi, Babylonian king of the 18th century B.C., foresaw that the physician who made a wrong diagnosis or treatment should have his hands amputated as a form of punishment for the error²⁸Hoirisch A. Ser médico, implicações históricas e antropológicas. São Paulo: Casa do Psicólogo; 2006.. Figuratively, the “amputation” that physicians suffer by understanding that their omnipotence is not as perfect and exact as they believed could lead to a process of deterritorialization: a discontinuation of self-referential territory as proposed by Guattari and Deleuze & Guattari²³Deleuze G, Guattari F. Mil platôs – capitalismo e esquizofrenia. Rio de Janeiro: Editora 34; 1995. (Coleção Trans(2) ).,²⁴Guattari F. Caosmose: um novo paradigma estético. São Paulo: Editora 34; 1992. (Coleção Trans).. Often, the trigger of deterritorialization can be an experience of loss - either of infallibility or of un-affectability:

The bond with the user, in these cases, also produced an opening to another deterritorialization because, besides having to face the reality of her/his own imperfection, there was one more factor producing disturbing feelings: the pain of the other, which from the intercessor⁴Merhy EE. O cuidado é um acontecimento e não um ato. Trabalho, produção do cuidado e subjetividade em saúde: textos reunidos. São Paulo: Hucitec; 2013. meeting, allowed the doctor to look beyond the purely technical or professional. Schultz et al.¹⁶Schultz K, Delva D, Kerr J. Emotional effects of continuity of care on family physicians and the therapeutic relationship. Can Fam Physician. 2012;58(2):178-85. describe that the bond and continuity of care can produce emotional distress in family doctors, especially when there is frequent contact with the user’s suffering, or when attempts to solve such suffering are unsuccessful. Da Silva & Teixeira³¹Da Silva ALP, Teixeira MAA. A angústia médica: reflexões acerca do sofrimento de quem cura. Cogitare Enferm. 2002; 7(1):75-83. quote that “the doctor is seen (even by himself) as the one who should know, and if he does not, it is because he is not a good doctor” (p. 6). In the interviews, some doctors reported that the suffering they experienced actually elicited questions about their professional capacity, and even surfaced their desire to give up medicine:

Several authors¹⁷Ramirez AJ, Graham J, Richards MA, Cull A, Gregory WM. Mental health of hospital consultants: the effects of stress and satisfaction at work. Lancet. 1996; 347(9003):724-8.,³²Balint M. O médico, seu paciente e a doença. Rio de Janeiro: Atheneu; 1988.

Romani M, Ashkar K. Burnout among physicians. Libyan J Med. 2014; 9:235-56.-³⁴Gonçalves CIRVB. Síndrome de Burnout em estudantes de medicina [tese]. Porto, PT: Instituto de Ciências Biomédicas Abel Salazar, Universidade do Porto Centro; 2016. comment on the possibility of developing a professional callousness by those who, when trying to deal with instabilities and uncertainties of the profession, understood that the distance from the pain of the other would be a safer path. They took refuge in rationality, in technicalism, in hard and light-hard technologies⁴Merhy EE. O cuidado é um acontecimento e não um ato. Trabalho, produção do cuidado e subjetividade em saúde: textos reunidos. São Paulo: Hucitec; 2013., as we would say. Some may even experience a kind of depersonalization, emotional indifference, and negative feelings towards users³³Romani M, Ashkar K. Burnout among physicians. Libyan J Med. 2014; 9:235-56..

Recognizing and analyzing one’s own identity territory can be a path to another recognition, and possibly this will happen over the years, as doctors experience different situations that place them confronting cracks in their territory. In fact, most of the doctors who brought to the interview elements of a reconfiguration of existential territory were the MJs (over 31 years old) as well as the “experienced”. The resident doctors were less explicit in this sense.

These facts raise some questions: would it still be possible to process, during medical training, the disturbing aspects of medical identity territory, in order to reduce suffering and make possible a widening of this territory, a flexibilization of it providing more satisfaction for both doctors and users, in times of deterritorialization? How to support doctors in the sense of re-territorialization in a territory that is more caring for themselves and the others, in a user-centered perspective?

Some of these points have been worked on in medical residency programs when there is stimulus to the development of communication skills, to the development of bonding, to the recognition of the user as the central object of care, as in PCCM²Stewart M, Brown JB, Weston WW, McWhinney IR, McWilliam CL, Freeman TR. Medicina centrada na pessoa: transformando o método clínico. 3a ed. Porto Alegre: Artmed; 2017.,¹³Caprara A, Rodrigues JV. A relação assimétrica médico paciente: repensando o vínculo terapêutico. Cienc Saude Colet. 2004; 9(1):139-46.,³²Balint M. O médico, seu paciente e a doença. Rio de Janeiro: Atheneu; 1988.,³⁵Ribeiro MMF, Amaral CFS. Medicina centrada no paciente e ensino médico: a importância do cuidado com a pessoa e o poder médico. Rev Bras Educ Med. 2008; 32(1):90-7.. There are also experiences of encouraging residents and medical specialists to self-knowledge and self-care, through psychotherapy, participation in Balint groups, stimulation of practices that can reduce emotional overload such as contact with art, the exercise of spirituality, or through Integrative and Complementary Practices¹⁸Puffer JC, Knight HC, O’Neill TR, Rassolian M, Bazemore AW, Peterson LE. Prevalence of burnout in board certified family physicians. J Am Board Fam Med. 2017; 30(2):125-6.,¹⁹Visser MR, Smets EM, Oort FJ, De Haes HC. Stress, satisfaction and burnout among Dutch medical specialists. CMAJ. 2003; 168(3):271-5.,³²Balint M. O médico, seu paciente e a doença. Rio de Janeiro: Atheneu; 1988.,³⁴Gonçalves CIRVB. Síndrome de Burnout em estudantes de medicina [tese]. Porto, PT: Instituto de Ciências Biomédicas Abel Salazar, Universidade do Porto Centro; 2016.,³⁶Tesser CD, Sousa IMCD. Atenção primária, atenção psicossocial, práticas integrativas e complementares e suas afinidades eletivas. Saude Soc. 2012; 21(2):336-50.. The interviewees also cited such strategies:

Much more than an effort to get a distance from users, the deterritorialization experienced (and allowed) by the interviewees made possible reconstructions of the medical territory in other configurations, with the production of territories sometimes more caring for themselves and the other. It is when this search to rearrange the existential territory points to a re-territorialization in another place, a displacement to a “caring place”⁴Merhy EE. O cuidado é um acontecimento e não um ato. Trabalho, produção do cuidado e subjetividade em saúde: textos reunidos. São Paulo: Hucitec; 2013..

This speech shows the physician’s movement towards re-territorialization where recognizing one’s vulnerability becomes something acceptable and even desirable. A shift that extrapolates the individual and becomes a collective process is then allowed: another “being a doctor” is possible for both the professional and the user. And the bond, strengthened in the intercessor encounter, is capable of producing in the doctor feelings of satisfaction, fulfillment and belonging. In this process of another recognition of oneself, it is understood that the role of physicians linked to their users transcends possible outcomes that are measured only by hard and light-hard technologies³Merhy EE. O ato de cuidar: a alma dos serviços de saúde. In: Brasil. Ministério da Saúde. Secretaria de Gestão do Trabalho e Educação na Saúde. Departamento de Gestão da Educação na Saúde. Ver-SUS Brasil: caderno de textos. Brasília: Ministério da Saúde; 2004. p. 108-37.,⁴Merhy EE. O cuidado é um acontecimento e não um ato. Trabalho, produção do cuidado e subjetividade em saúde: textos reunidos. São Paulo: Hucitec; 2013.:

Caprara & Rodrigues¹³Caprara A, Rodrigues JV. A relação assimétrica médico paciente: repensando o vínculo terapêutico. Cienc Saude Colet. 2004; 9(1):139-46. discuss the asymmetrical relationship between physicians and users, in the sense that physicians are holders of the totality of knowledge from which the user is generally excluded. Seixas et al.⁷Seixas CT, Baduy RS, Cruz KT, Bortoletto MSS, Slomp Junior H, Merhy EE. O vínculo como potência para a produção do cuidado em saúde: o que usuários-guia nos ensinam. Interface (Botucatu). 2019; 23:e170627. reinforce the role of the bond in establishing symmetrical relationships, in which the health user is seen as a valid interlocutor, and whose knowledge has equal or greater importance in the construction of care. The position of controller over the life of the other then gives way to a de-territorialization capable of empowering the self-analytical process of care production, deconstructing the figure of the omnipotent physician and producing encounters with symmetry of power.

Especially when we speak of a bond constituted of symmetry of power and knowledge, the deconstruction of the image of the infallible doctor brings with it a reassuring potential. Many interviewees reported feeling more secure because they are linked to users, with less fear of failure and more power in facing problems, while the idealization of the omnipotent doctor is undone:

Moreover, the bond establishes itself as fertile ground for the intercessor encounter to take place and be translated into care, where the subjects give up their position of dominion over the other and give themselves over to a shared construction of care, allowing themselves to reveal their non-knowledge and be affected, not only by suffering and fragility, but especially by the power of life of the other⁴Merhy EE. O cuidado é um acontecimento e não um ato. Trabalho, produção do cuidado e subjetividade em saúde: textos reunidos. São Paulo: Hucitec; 2013.,⁷Seixas CT, Baduy RS, Cruz KT, Bortoletto MSS, Slomp Junior H, Merhy EE. O vínculo como potência para a produção do cuidado em saúde: o que usuários-guia nos ensinam. Interface (Botucatu). 2019; 23:e170627.. And for the doctor who is daily exposed to the difficulties of the profession, self-knowledge linked to users can play a more invigorating role, rather than an exhausting one. The symmetry that produces bond goes beyond relationships of knowledge and power and becomes a “symmetry of care”: doctors gains potency in acting because they feel bonded to their users, producing new possibilities of care for the other and for themselves, understanding that whoever provides the care can also receive it, in the same act, because it is an intercessor encounter:

When experiencing the bond, and in order to experience it in all its intensity, doctors have the chance to leave behind the labels of omnipotent, inaccessible, infallible, allowing themselves to experience this encounter without prejudice and/or defined expectations. In this movement, both physicians and users pass through the caring dimension of the encounter, in a space where both allow themselves to be heard and to be heard, to be cared for and to be taken care of. The bond itself stimulates the reconstruction of a new existential territory with more potentiality, which goes far beyond a discursive repetition fragile, imposed, and unquestioned. Such potential comes from the encounter thus experienced, and leads to a deactivation of that identity territory that once seemed solid, armored, immutable. In this way, the light technologies, already decisive in the process of deterritorialization that are effective, now begin to be operated with even greater ease, and the caring encounter materializes in a territory filled with new possibilities of configurations of care for oneself and the other.

Final considerations

The origins of medical identity territory go back to the origins of humanity itself, possessing elements that give body to the idea of power and infallibility of the doctor. In several ways doctors can experience a deconstruction of their self-referenced existential territory, perceiving themselves as impotent, fallible, imperfect. The result of this may be callousness, as if in an attempt to avoid the discontinuation of their place of omnipotence, re-territorializing themselves in a reinforcement of the identity of “being doctors”. Or, when another deterritorialization happens, it can lead to feelings of suffering and anguish, and illness.

On the other hand, in the context of the intercessor encounter, doctors experience, in the acts of health care, the possibility of bonding with their users, and from the symmetrical bonds may provoke re-territorializations in which doctors assume their ignorance and discards the idea of omnipotence to tread a new ground with their patients: a caring encounter.

Even as watertight as socially accepted medical identity might appear to be, medical identity territory can be partially deactivated and diverted in other re-territorializations in a dynamic and constant manner. Whether it is for disarming oneself from a posture of infallibility, for recognizing the potency and knowledge of the other (user, team), or for allowing oneself to be affected by the feelings of the other and recognizing that there is potency to act in this encounter, doctors can then make use of their experiences in the reconstruction of their professional identity.

Above all, bonds will play a central role in the re-territorializations, as doctors incorporate as a new value the potency of the caring encounter for themselves and the others. As tectonic plates in movement, medical identity territories may then assume a dynamic character, producing deviations and new configurations of “doing medicine”, in a constant transformation in which light technologies can be intensely operated in the framework of the caring encounter.

References

Publication Dates

History