Rev Electron Biomed / Electron J Biomed 2005;1:22-31 Teixeira. COMPETENCE IN MEDICINE

RESUMEN
La competencia en el ejercicio de la Medicina depende de un proceso evolutivo a lo largo de la vida profesional, proceso éste fundamentado en la eficiencia, experiencia y en principios éticos. La eficiencia depende de la cultura médica, de las habilidades técnicas y de relaciones interpersonales con el paciente. La experiencia a lo largo de la vida va refinando al médico, favoreciendo el desarrollo del conocimiento y la sabiduría vivencial. Finalmente, la ética médica se fundamenta enla justicia, compasión y amor por el prójimo. Didácticamente, distinguimos 3 fases de evolución profesional del médico: a) Infancia profesional o visión lineal: el médico se restringe en general a atender la enfermedad, olvidando al enfermo. Es casi exclusivamente técnico y tiene una perceptión limitada de la medicina como un arte. b) Madurez profesional o visión humanística: resultado de la evolusión de la personalidad, de la cultura y de la experiencia del médico, ahora vuelto al enfermo y su enfermedad. c) Excelencia profesional o visión holística: estadío máximo que se puede alcanzar, cuando el médico se vislumbra a sí mismo y a su cliente en todas sus dimensiones integradas y actúa como maestro, procurando despertar en el paciente condisiones propias de la curación, oriundas de su esencia. Se concluye que ejercer la medicina con competencia significa desempeñar adecuadamente la ciencia y el arte médico

RESUMO
Competência no exercício da medicina depende de um processo evolutivo ao longo da vida do profissional, processo este fundamentado em eficiência, experiência e em princípios éticos. A eficiência depende da cultura médica, de habilidades técnicas e relacionamento interpessoal com o paciente. A experiência ao longo da vida vai refinando o médico, favorecendo o evolver do conhecimento e da sabedoria vivencial. Finalmente, a ética médica se fundamenta na justiça, compaixão e amor ao próximo. Didaticamente, distinguimos 3 fases da evolução profissional do médico: a) infância profissional ou visão linear: o médico se restringe em geral ao atendimento da doença, negligenciando o doente. É quase exclusivamente técnico e tem percepção acanhada da medicina-arte. b) Maturidade profissional ou visão humanística: resultado de evolução da personalidade, da cultura e da experiência do médico, agora voltado para o doente com sua doença. c) Excelência profissional ou visão holística: estágio máximo que se pode alcançar, quando o médico vislumbra a si e ao seu cliente em todas suas dimensões integradas e atua como mestre, procurando despertar no paciente condições próprias de cura, oriundas de sua essência. Conclui-se que exercer medicina com competência significa desempenhar adequadamente a ciência e a arte médica.

SUMMARY
Medical competence is the result of a lifelong evolving process, based on the development of efficiency, experience and ethical principles. Efficiency in medical practice depends on scientific knowledge, technical abilities and communication skills. Experience is a process of personal refinement, breeding knowledge and wisdom. Finally, medical ethics is founded on the quest for justice, compassion and love. Didactically, we can distinguish three phases in the professional evolution of a physician: a) Professional infancy, or linear vision: the physician restricts his attention to the morbid process only, often neglecting the patient in his totality. His approach is almost exclusively technical, with limited perception of medicine as an art. b) Professional maturity or humanistic vision: it results from the evolution of personality, culture and experience of the physician, who foccuses now on the patient as a whole with his disease(s). c) Professional excellence, or holistic vision, the highest stage: when the physician's integrated dimensions and wisdom are projected into the patient, fostering the natural conditions for optimal healing. We conclude that the practice of medicine is best fulfilled when both, art and cience, are considered and exercised together by the doctor.

Palabras Clave: Medicina Clínica, competencia médica, holismo y medicina

Descritores: medicina clínica; competência em medicina; holismo e medicina.

Keywords: clinical medicine; medical competence; holism and medicine.

At fifteen, I aspired to learning.
At thirty, I established my stand.
At forty, I had no delusions.
At fifty, I knew my destiny.
At sixty, I knew truth in all I heard.
At seventy, I could follow the wishes of my heart without doing wrong.
(Confucio, cap 2, v4, Lun Yü)

INTRODUCTION
"Medicine is of all the Arts the most noble... Whoever is to acquire a competent knowledge of medicine, ought to be possessed of the following advantages: a natural disposition; instruction; a favorable position for the study; early tuition; love of labor; leisure. First of all, a natural talent is required". This statement, attributed to Hyppocrates ¹ (c 460-377 a.C.), stresses the fact that physician's competence is not strictly limited to knowledge (science and technology), but also depends on other attributes, especially art. Art, in this context, is the enriching source of emotions and enables the physician to mobilize all his cognitive, moral and spiritual resources to benefit the patient. The physician's work not only demands intelligence, rational thought, deductive and analytical skills, but, also, intuition, emotion, sensitivity and synthesis. Such qualities bring to the physician a natural attitude of respect, kindness, understanding, honesty and competence. However, these individual and unique attributes are not always equally recognized. These genuine human qualities could never be adequately replaced even by the most advanced computers. Lately, it has been noted that, in the course of their work, physicians seem to be more interested in the technical aspects, rather than in the art of medicine. The rapid progress in the fields of science and technology, especially during the second half of the last century, has definitely been a major contributor to this trend. The understanding of disease processes, the establishment of diagnostic and treatment methods were deeply transformed by this progress. In order to provide society with better physicians, modern medical schools are giving priority to the latest technological advances. This tendency has progressively neglected medicine as an art, resulting in a less humane and more technical approach to patient care. Siqueira, former president of Associação Brasileira de Educação Médica (ABEM) (Brazilian Association of Medical Education) stated: "Newly graduated physicians...have actually become equipment dependent, like technicians amazed at their wonderful machines... little do they know about medicine, and even less about their patient. If medical schools are graduating their students based only on the acquisition of high technology, they are degrading, rather than graduating them"².

Foundations of competence in Medicine
Competence in medicine can be described as the ability to utilize all the necessary cognitive and technical resources, sufficient to diagnose, treat and provide maximum benefit to the patient, with the least cost and morbidity. Such resources should be utilized within ethical standards, reflecting the scientific evidence and personal experience. The organic or segmental view of the human body, first described by Galen³and later developed by Descartes (1596-1650 a.D.), led to the disassembling of the human body into smaller parts, reducing it to a machine. This notion led to the development of medical specialties. The new specialist has a deeper (vertical) knowledge of an organ or system and utilizes more advanced technical resources to diagnose and treat diseases in his field of expertise. However, the specialist, with rare and notable exceptions, tends to have a more limited and insufficient perception of the patient's complex nature. This fragmentation of medical knowledge into specialties has been the object of criticism, because the complex interconnections between body and mind, conscience and spirit, which are integrated as human nature, cannot be equally separated⁴. It becomes evident that this segmental approach to organs or systems, in itself, is an insufficient method to address all the patient's needs. This brings into question the real competence of the modern physician. We understand that competence in medicine should be based on three fundamental values: efficiency, experience and ethics (fig. 1).

Fig. 1. Competence in medicine

Medical competence is based on the three foundations above mentioned, all being considered essential and interdependent conditions for excellence. The concept of efficiency includes three elements²: medical knowledge or culture, psychomotor and communication skills.

Through personal experience and assimilation of medical information from available sources, physicians must first identify the practical benefits of his acquired knowledge before applying it. This process needs to be consciencious and careful, in order to secure appropriate guidelines for patient care. Such a practice is known as "evidence based medicine", and has been adopted by the medical community worldwide, since its inception in 1992⁵.

However, when applying all this body of evidence, based on experimental studies, the physician has also to consider each patient's individual and unique needs. It is important to remember that similar diseases affect patients differently, because of each one's unique response. Dantas e Lopes⁶ recently proposed a new concept entitled "competence based medicine", as a response to the excessively impersonal nature of medical care during the recent past, which is based almost exclusively on scientific evidence. This new concept allows the physician to integrate medical ethics and scientific truth according to his own personal experience. The second element for consideration, personal experience, allows the physician to master his art and better utilize his resources and personal skills to benefit his patients. His experience will make him more sensitive and thoughtful, supplement his knowledge, enhance his analytical and deductive skills, as well as his ability to question, and interpret, and listen to his patient. "Observation is the foundation of medical practice. Theories may come and go, but the power of observation will always remain present. The genius of observation lives forever" (Cardarelli, cited by Dantas, Lopes⁶).Last, but not least, comes the third element, ethics. It symbolizes respect for justice, compassion and love, and the genuine interest in helping our fellow man. It also represents respect for the fundamental rights for life and liberty, independently of gender, race, religious beliefs, social class or even the type of disease that afflicts him or her. The physician's performance in the care of his patient should always be guided by ethical principles. These principles, both in medicine as well as in society at large, promote a more cordial and deeper patient-physician relationship. This strong bond between physician and patient may become an important catalyst for cure ^{4, 7, 8}.

A recent joint publication of the European Federation of Internal Medicine, American College of Physicians - American Society of Internal Medicine (ACP-ASIM) and American Board of Internal Medicine (ABIM) suggested the following guidelines describing patient rights⁹, sugerindo a observância dos seguintes princípios básicos e compromissos profissionais por todos os médicos, qualquer que seja o seu local de trabalho no mundo:

Fundamental principles:

A set of professional responsabilities:

"Professionalism is the basis of medicine's contract with society. It demands placing the interests of patients above those of the physician, setting and maintaining standards of competence and integrity, and providing expert advice to society on matters of health"⁹.

Objectives of the competent physician
The purpose of medicine is to provide every person with the means for a safe birth and a comfortable death, to protect health and cure illness whenever possible, to relieve and comfort those who suffer and to provide lifelong care to the handicapped (T.Mckeown, 1980)¹⁰. The physician should understand that these broad objectives might not always be feasible, but they should remain his ultimate goals. In order to reach his highest level of efficiency, the physician should be able to address both the patient and his disease. In other words, he should know and understand the patient's complexity and constitution, as well as how his disease affects his life and his social environment. As he analyses the biological, psychological, social and spiritual dimensions of his patient and his disease, reaching their root causes, he has a better understanding of their entire spectrum. This could be the ideal approach to inspire his patient's compliance and to establish a deeper and more comprehensive treatment plan^4,11,12,13. This global approach can be decisive for a succesful outcome. In order to reach cure for a disease, the physician should utilize all his available means, such as promoting good quality of life and respecting his patient's rights and, also, prolonging his life expectancy, based on clinical evidence and his experience.

The Evolution of Medical Competence
With few exceptions, the curriculum currently adopted by western medical schools, including brazilian ones, is almost exclusively dominated by organic and biological concepts. The graduate medical education is, by nature, slow and progressive, going through successive stages. They can be classified as infancy, maturity and excellence¹⁴.

First stage - Professional infancy = linear perception.
This stage represents the first steps of the student's professional development. At school, he opens his heart to the learning process and absorbs large amounts of totally new information. His inital anecdotal concepts about health, disease and patient are gradually replaced by sound scientific information. As he begins his hospital clerkship, he is very curious and attentive to what he learns, but is still unable to conduct a critical analysis. His hospital experience will gradually expose him to the challenges and responsibilities of medical practice. At the end of his school years, he will almost always feel somewhat incompetent and insecure, and will try to pursue some post-graduate education before working independently. Usually, he will then start his residence program. During this period he will acquire more experience and knowledge and slowly build his professional self-confidence. Evidence based medicine will be particularly appealing to him, but he still will be swayed by the strong influence of the pharmaceutical representatives, occasionally prescribing medications advertised as "the most modern and efficient", before submitting them to a more rigorous evaluation. His prescription habits can be particularly influenced by expensive dinners or small gifts^{15, 16}. He will follow the general principles within his limited global perception of medicine. He will grasp a good knowlege about disease, but still will tend to ignore the person behind the patient. He tends to become somewhat inflexible, imposing his decisions to the patient, even when they can be associated with increased costs or risks, occasionally causing iatrogenic complications more severe than the disease itself. This initial phase certainly poses an increased risk to the patient, but is the initial step of a slow and long learning experience. It is a phase limited by a linear conscience, the first conceptual dimension of the entire professional evolution: he is able to visualize only what is in front of him. Many physicians will remain stranded in this initial phase. Others will be able to envision the greatness of their mission and broaden their horizons, reaching the next phase.

Second stage - Professional maturity = humanistic perception.
At this stage the physician can look back at his past, mostly dedicated to medicine; he has already faced many challenges, and had his share of success and failures. He gradually becomes emotionally mature and is able to inspire confidence in his clients and friends. He becomes very meticulous when performing clinical examinations and very skillful when obtaining the most pertinent information from his patients. He can expeditiously assimilate, compile, organize and interpret all that information in great detail. He can then generate a diagnostic and therapeutic plan, aiming not only to relieve the disease but also to bring him lasting comfort. During this phase, he carefully carries out his plan without haste, with finesse and a coherent thought process. His maturity makes him humble about his knowledge and he constantly questions his own abilities. He is very prudent when utilizing technological resources, avoiding increased costs or possible morbidity to the patient. His approach is to adjust, that is, to individualize, present and discuss his thoughts and plans, rather than imposing his knowledge and technique to the patient. He becomes a good listener, demonstrating a deeper and broader conscience, far beyond the linear vision of his professional infancy. He becomes a keen observer and a deeper thinker in his decisions aimed to benefit his patients. Obviously this stage of his profession is an evolving process and greatly depends on the individual characteristics of the physician, his unique personality, factors which will determine his unconditional dedication, empathy and coherence of thought¹⁷.

Third stage - Professional excellence = holistic perception.
This stage combines the ultimate manifestation of the physician as human being and as a scientist, a model of competence, coherence and wisdom. At this level he has developed a profound understanding of his own self and of his patients. He is fully capable to integrate science and conscience. He is eager to bring to his patients the conditions that will lead to the ultimate cure of their illness, based on the their essencial nature. "This endeavor requires from the physician other higher qualities such as being a master, a guru...." (Durckheim apud Crema¹⁸). His recommendations and convictions will always carry great impact because they reflect the depth of his knowledge and are transmitted with humility and respect. He becomes recognized not by his academic titles, but mostly for his inner wisdom and benefits he is able to bring to his patients¹⁷. His knowledge reaches beyond the limits of science. His intuition or ability to see the truth gives him mystic qualities. He is a master. Confucio reached this stage at age seventy, when he "could follow the wishes of (his) heart" without the fear of failure. This phase is also recognized by Ubaldi ¹⁹ as "superconscience": " ... It is not a matter of adding facts, observations and discoveries or multiplying the achievements of science, but about inner change. Not the slow and imperfect mechanism of reason, but deep and rapid intuition. Not the outward projection of conscience, through the superficial touch of our senses, but its inward expansion, which will enable us to touch the real essence of everything"¹⁹. This stage represents a higher level of intelectual activity for the physician, reaching beyond the linear vision of his infancy and also beyond his humanistic vision. It now encompasses the holos, the universal dimension of human beings. His zeal to relieve suffering is filled with love and compassion. He is capable of visualizing the most sensitive dimensions of those who seek him and utilize them as tools of guidance and transformation. It is a stage seldom reached by all. Those who reach it are in harmony with nature and will be blessed with deep inner peace.

Final comments
In order to become fully competent, the physician needs to develop a certain number of attributes, besides just graduating from a recognized medical school, mastering technological or procedural skills or even posessing broad medical knowledge. These conditions are definitely necessary, but not sufficient for such endeavor. A competent physician must recognize his patient as a complex human being, who happens to be afflicted by an illness and his approach should not separate them. His knowledge about human beings should encompass all their real dimensions, where he will find the diverse sources or consequences of the existing problems. As the physician pursues his own moral, spiritual and cognitive growth, by following ethical principles in his practice, he will also enjoy the development and growth of his own competence. His work, will not only be an academic or scientific activity, but also an artistic, loving and compassionate experience. The ultimate object of the competent physician is the essence of the human being, the great purpose of his existence. Medicine is his vocation and instrument to serve. He sets himself apart from the strictly professional physician, who practices medicine simply to earn a living or to enrich himself, without any regard for his own competence. Every physician should set his goals into achieving the highest levels of professional development, such as maturity and excellence, and truly become a physician for body and soul (T. Caldwell).

Acknowledgement: I am deeply grateful to Alfredo O. Xavier, MD, for the Englisch version and revision of the text.

REFERENCES:

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2. Teixeira H., Dantas F. O Bom Médico. Rev Bras Educ Méd. 1997;21:39-46.

3. Enciclopédia Mirador Internacional, vol. 10,São Paulo:Enc. Britannica do Brasil Publ. Ltda.,1987. 5080p.

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http://www.uninet.edu/cin2001/html/conf/teixeira/teixeira.html. Acesso: 20 dez.2002

5. Evidence-Based Medicine Working Group. Evidence-Based Medicine: a new approach to teaching the practice of medicine. JAMA 1992;268:2420-2425.

6. Dantas F. Lopes AC. Medicina embasada na competência. Revista Brasileira de Clínica e Terapêutica 2002;28:88-90.

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8. Rose M. et al. The network of psychological variables in patients with diabetes and their importance for quality of life and metabolic control. Diabetes Care 2002;25:35-42.

9. Medical Professionalism in the New Millenium: A Physician Charter. Project of the ABIM Foundation, ACP-ASIM Foundation, and European Federation of Internal Medicine. Ann Intern Med 2002;136:243-246.

10. Mckeown T. The role of medicine: Dream, Mirage or Nemesis? Princeton, Princeton University Press, 1980.

11. Lissoni P et al. A review on cancer psycho-spiritual status interactions. Neuroendocrinol Lett 2001;22:175-80.

12. Hebert Rs et al. Patient perspectives on spirituality and the patient-physician relationship. J Gen Intern Med 2001;16:685-92.

13. Post SG et al. Physicians and patient spirituality: professional boundaries, competency and ethics. Ann Intern Med 2000;132:578-83.

14. Crema R. Saúde e Plenitude: um caminho para o ser. São Paulo: Summus Editorial, 1995.

15. McKinney WP et al. Attitudes of internal medicine faculty and residents toward professional interaction with pharmaceutical sales representatives. JAMA 1990;264:1693-7.

16. Royal College of Physicians. The Relationship between physicians and the pharmaceutical industry. Journal of the Royal College of Physicians of London. 1986;20:235-42.

17. Rogers C. On becoming a Person. Eugene T. Gendlin, University of Chicago. From: American Psychologist V.43 [Feb.1988]

18. Crema R. Introdução à Visão Holística: breve relato de viagem do velho ao novo paradigma. São Paulo: Summus editorial,1988.

19. Ubaldi, P. A Grande Síntese. 19.ed. Campos de Goytacazes: Fraternidade Francisco de Assis, 1997.

Comentario del revisor, Ramón Díaz-Alersi, MD. Medicina Intensiva. Hospital Puerto Real. Cádiz. España

(Tradução ao Português)
A Ciência é um fenómeno recente na História. Com início na Grécia clássica, o seu desenvolvimento associa-se à chamada Revolução Científica do século XVII. Considera-se assim que o ponto de partida foi a execução na fogueira de Giordano Bruno no ano 1600 em Roma. Até essa data (e também depois) tem havido outros métodos diferentes do científico que tentaram explicar a realidade física, como o pensamento mágico, os dogmas religiosos ou as diferentes opiniões publicas. O campo do conhecimento científico está incluído na realidade lógica e desde o inicio, quase todas as áreas do conhecimento humano têm tentado basear-se nele. Os conhecimentos adquiridos através do método científico têm como característica principal a reprodutibilidade. Sem chegar à demonstração matemática, a única que obtem as verdades absolutas, as teorias científicas apoiam verdades que apenas são aceites quando as provas que as apoiam são esmagadoras, e ainda que uma só prova em contra possa deitar por terra a teoria até ao ponto de obrigar abandona-la enquanto se sustem proporcionam um método pelo qual qualquer um com os médios e a preparação suficientes pode reproduzir os resultados.
São evidentes as vantagens da aquisição do conhecimento por este método e por isso, todas as disciplinas têm tentado adoptá-lo. A medicina também o fez, embora tenha atingido o status de ciência muito mais tardiamente em comparação com outras disciplinas do conhecimento.
Não entanto a medicina não é apenas um ramo do conhecimento, já que trata com seres humanos sendo o seu alvo a saúde e o bem-estar. Tentar reduzi-la a um ramo da ciência, tem dado lugar a erros tais como a consideração do corpo como um objecto mecânico composto de partes mais simples e com um tratamento independente. O médico contemporâneo, pressionado pela necessidade de adquirir conhecimentos válidos pode cair na tentação de esquecer outros aspectos fundamentais da profissão e não tratar o doente como um ser humano, a quem a doença pode influenciar de diversas formas, nem sempre abordáveis com os conhecimentos que a ciência proporciona.

(Original en Español)
La Ciencia es un fenómeno reciente en la Historia. Aunque se da por sentado que surgió en la Grecia clásica, su desarrollo está vinculado con la llamada Revolución Científica del siglo XVII. Se suele considerar como su punto de partida la ejecución en la hoguera de Giordano Bruno en 1600 en Roma. Hasta entonces (y también después) ha habido otros métodos distintos del científico para explicar la realidad física, como el pensamiento mágico, los dogmas religiosos o las diferentes formas que moldean las opiniones públicas. El campo del conocimiento científico está incluido dentro de la realidad lógica y desde su surgimiento, casi todas las áreas de conocimiento humano han intentado fundamentarse en él.
Los conocimientos adquiridos mediante el método científico tienen como característica principal su reproductividad. Sin llegar a la demostración matemática, la única que conduce a verdades absolutas, las teorías científicas sostienen verdades que sólo son aceptadas mayoritariamente cuando las pruebas que la apoyan son abrumadoras y, aunque una sola prueba en contra puede socavarla hasta el punto de obligar a abandonarla, mientras se sostienen, proporcionan un método mediante el cual cualquiera con la suficiente preparación y medios puede reproducir los hallazgos de otros.
Es evidente la ventaja de la adquisición de conocimiento por este método y por ello, todas las disciplinas han intentado adoptarlo. La Medicina también lo ha hecho, aunque ha llegado al status de ciencia mucho más tarde que otras ramas del saber. Sin embargo, la medicina no es solo una rama del saber, trata con seres humanos y su objetivo es su salud y su bienestar. Intentar reducirla a una rama de la Ciencia ha dado lugar a errores como la consideración del cuerpo humano como un objeto mecánico compuesto de partes más simples cuyo tratamiento puede ser independiente. El médico de nuestro tiempo, abrumado por la necesidad de adquirir conocimientos válidos puede caer en la tentación de olvidar otros aspectos fundamentales de su profesión y no tratar a su paciente como un ser humano, en el cual la enfermedad influye de muchas maneras, no todas abordables con los conocimientos que la Ciencia proporciona. Este excelente artículo llama la atención sobre este problema y proporciona algunas respuestas para solucionarlo.

Comentario del revisor, Prof. José María Eirós Bouza MD. PhD. Titular de Microbiología. Facultad de Medicina. Universidad de Valladolid. España

(Tradução ao Português)
Este trabalho situa-se na área da reflexão conceptual acerca da Competência profissional na Medicina. O autor faz uma exposição estruturada na qual revê aspectos relativos aos princípios fundamentais nos quais se baseiam a actividade profissional e os seus limites. Este trabalho mostra experiências pessoais e conclui relatando o que denomina as três fases da evolução profissional.
A oportunidade que o Prof. Teixeira nos oferece é um desafio para aqueles que exercem a medicina desde âmbitos distantes dentro da especialização, dado que representa uma chamada integradora para a essência da profissão. A sua leitura e análise podem abrir sem dúvida, novos horizontes de desenvolvimento pessoal desde âmbitos muito diferentes. O comentário acrescido dos nossos leitores pode animar-nos a receber e publicar artigos como este, cuja difusão não deve ser esquecida.

(Original en Español)
La presente contribución se sitúa en el ámbito de la reflexión conceptual sobre la "Competencia" profesional en Medicina. El autor establece una exposición estructurada en la que revisa aspectos relativos a los principios fundamentales en los que asienta hasta los compromisos que delimitan la actividad profesional. En su desarrollo establece aportaciones personales y concluye narrando lo que él denomina tres fases de la evolución profesional.
La oportunidad que nos ofrece el Prof Teixiera supone un reto para cuantos ejercemos la medicina desde ámbitos muy distantes en cuanto a la especialización, en el sentido de que representa una llamada integradora a la propia esencia de la profesión. Su lectura y análisis puede abrir,sin duda, nuevos horizontes de desarrollo personal desde ámbitos muy plurales. El comentario adicional de nuestros lectores puede animarnos a recibir y publicar artículos como el presente, cuya difusión no debe ser descuidada.

Comentario del revisor Jesús Garrido MD. Unidade de Nefrologia e Diálise. Hospital São Teotónio de Viseu. Viseu. Portugal

(Original en Portugues)
"A doença é muito velha e nada acerca dela tem mudado. Somos nós os que mudamos, conforme aprendemos a reconhecer o que antes era imperceptível" Jean Martin Charcot (1825-1893).

Apesar do percurso evolutivo da Medicina desde a antiguidade tem sido nas últimas décadas quando tem caminhado com passos de gigante. As descobertas nas diferentes áreas relacionadas com a medicina (biologia, farmacologia, física, química…) e um conhecimento mais aperfeiçoado da fisiopatologia humana tem permitido grandes avanços nesta área e também tem contribuído para alguma mudança na forma de entender esta arte. Assim, a medicina actual ou tecnológica tem certa tendência para o esquecimento da clássica, a "Hipocrática" que deveria manter-se como pilar básico do conhecimento e sobre o qual deveria ser desenvolvido o conhecimento científico. Conciliar estas duas partes da medicina é a única via possível para manter esta profissão como a arte mais nobre. A competência em Medicina, como o Prof. Teixeira bem descreve neste trabalho é um processo de maturidade profissional e também pessoal, e deveríamos questionarmo-nos sobre isso no dia a dia no nosso trabalho. Apostar na correcta formação humanista e científica, na relação médico-doente, na experiência e na ética permitirá desenvolver esta competência.
"Aquilo que se deve pôr primeiro na prática da nossa arte é lograr que o doente melhore; se com muitas maneiras não consegue melhorar, devemos escolher o menos problemático" Hipócrates. Isto, que de forma geral é o resumo da nossa actividade não é muitas vezes bem percebido pela sociedade que exige a infalibilidade da Medicina. Derivada dessa exigência, surge um problema actual que colide com a competência, a medicina defensiva e que por sua vez alimenta uma medicina cada vez mais tecnológica. A medicina como ciência variável vê-se resumida nesta frase: "A variabilidade é a lei da vida e não há duas faces iguais, também não há dois organismos iguais, nem duas pessoas reagem igual, nem se comportam por igual nas mesmas condições anormais que nos conhecemos como doenças" Sir William Osler (1849-1919).
O trabalho do Prof. Hélio Teixeira aporta experiência pessoal e resume magnificamente os princípios básicos da medicina e a evolução que se espera de nós durante o exercício da profissão, em tempos difíceis para a arte.

(Original en Español)
"La enfermedad es muy vieja y nada acerca de ella ha cambiado. Somos nosotros los que cambiamos, conforme aprendemos a reconocer lo que antes era imperceptible" Jean Martin Charcot (1825-1893).
A pesar de la evolución de la Medicina desde la antigüedad, ha sido en las últimas décadas cuando ha caminado a paso de gigante. Los descubrimientos en las diferentes áreas relacionadas com la medicina (biología, farmacología, física, química…) y un mejor conocimiento de la fisiopatologia humana han permitido grandes avances en este área y han contribuido también para algún cambio en la forma de entender este arte. Así, la medicina actual o tecnológica tiene cierta tendencia para el olvido de la clásica, la "Hipocrática" que deberia mantenerse como el pilar básico del conocimiento y sobre el cual deberia ser desarrollado el conocimiento científico. Conciliar estas dos partes de la medicina es la única via posíble para mantener esta profesión como el arte mas noble. La competencia en Medicina, como el Prof. Teixeira bien describe en este trabajo es um proceso de maduración profesional así como personal y deberiamos cuestionarnos sobre eso en el dia a dia de nuestro trabajo. Apostar en la correcta formación humanista y científica, en la relación médico-paciente, en la experiencia y en la ética permitirá desarrollar esta competencia.
"Lo que se debe poner primero en la práctica de nuestro arte es lograr que el paciente mejore; si com muchas maneras no puede mejorar, uno debe escoger lo menos problemático" Hipócrates. Esto, que de forma general es el resumen de nuestro trabajo no siempre es bien entendido por la sociedad, que exige una Medicina infalible. Derivada de esa exigencia, surge un problema actual que choca com a competencia, la medicina defensiva y que a su vez alimenta una medicina cada vez mas tecnológica. La medicina como ciencia variable se ve resumida en esta frase: "La variabilidad es la ley de la vida y no hay dos caras iguales, tampoco hay dos organismos iguales, ni dos personas reaccionan igual, ni se comportan igual en las mismas condiciones anormales que conocemos como enfermedad" Sir Willian Osler (1849-1919).
Este trabajo aporta experiencia personal y resume magnificamente los principios básicos de la medicina y la evolución que se espera de nosotros durante el ejercicio de la profesión, en tiempos difíciles para el arte.

Received January 17, 2005.
Published January 27, 2005

COMPETENCE IN MEDICINE

Hélio Teixeira MD.

Professor Titular e Livre Docente. Departamento de Clínica Médica
Universidade Federal de Uberlândia (UFU) – Uberlândia (MG) - Brasil

hteixeira @ prove.ufu.br

Rev Electron Biomed / Electron J Biomed 2005;1:22-31

COMPETENCE IN MEDICINE

Hélio Teixeira MD.

Professor Titular e Livre Docente. Departamento de Clínica Médica Universidade Federal de Uberlândia (UFU) – Uberlândia (MG) - Brasil

hteixeira @ prove.ufu.br

Rev Electron Biomed / Electron J Biomed 2005;1:22-31

Professor Titular e Livre Docente. Departamento de Clínica Médica
Universidade Federal de Uberlândia (UFU) – Uberlândia (MG) - Brasil