WMA 70th President Inaugural Speech Final Version

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Dr. Miguel R. Jorge, World Medical Association 70th
President
Inaugural Speech, 25th of October 2019
Dear Colleagues and Friends,
Ladies and Gentlemen,
Thank you for your presence and enduring support to the
World Medical Association. It means a lot to the physicians
we represent and, at this particular ceremony, it also means
a lot to me.
Those of you familiar with the World Medical Association
know that our constituent members include one hundred
and twelve national medical associations. I am here today
being inaugurated as the World Medical Association’s 70th
President not by myself but representing not just my
colleagues from the Brazilian Medical Association but
millions of physicians who practice in every corner of the
globe.
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My home country, Brazil, is amongst the 10th biggest
economies but is also amongst the 20th most unequal
countries in the world. And we know that wealth
inequalities within a country impact social determinants of
health and consequently the health status of its population.
It is not uncommon to see, in unequal countries, two
realities for medical care: one with first world quality for
those who have more and the other of little quality – if any
– for the underprivileged.
The World Medical Association’s Declaration of Geneva
states in its opening remarks that physicians pledge to
dedicate their lives to the service of humanity and have the
health and well being of their patients as their first
consideration. We, as physicians, practice our commitment
to these principles not just when attending to our patients
but also when we join our medical associations in their
multiple activities, aiming, at the end, to raise the health
status and quality of life of the population we serve.
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There are many and different factors influencing the
physicians’ role to promote the health and quality of life of
others, such as a good and continuous medical education,
adequate resources and conditions for work – particularly
enough time with each patient, a balanced professional and
social life, and – equally important – to take care of their
own physical and mental health.
As a psychiatrist, I was planning to emphasize during my
Presidential term that there never will be health without
mental health. But I was challenged by myself to broaden
my concerns, and remind and highlight to my fellow
physicians one essential component of the practice of
Medicine: the great value of the physician-patient
relationship.
It is usually recognized that most of those who are looking
to enter medical school, do so saying they want to help
people in their suffering related to illness. But studies from
different countries show that medical students usually are
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less sensitive to the patient’s needs as a person when
finishing than they are when entering medical school.
What happened in between? One possible reason is that
students, during their medical education, are more and
more exposed to the biological nature of illnesses than to
the social environment surrounding their patients and the
development of diseases. They also are not adequately
taught to take into consideration the emotional aspects of
those they are assisting.
To those who are being trained to be a medical doctor,
biology is an arena where they feel more secure and
comfortable to act than they do when feeling incapable of
dealing with people’s social and psychological issues.
Besides that, the physicians-to-be were developing
defences against their own suffering when facing different
forms of pain in their patients. Physical pain, emotional
pain, social pain. And these defences reduce their
sensibility to others’ needs.
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A good physician needs to be able to put him/herself in the
place of their patients, trying to feel as they feel, in order to
better understand their needs and plan to provide what they
need more. But it is not a simple task to put him/herself in
the place of a patient and – at the same time – to avoid
feeling as helpless as the patient would be. In medical care,
it is as essential to have empathy as it is to be able to
examine the patient from the outside.
A colleague from my Department in the Federal University
of São Paulo, Dr. Julio Noto (personal communication),
reported to me that once he heard from one of his Medical
Psychology students: “How can I talk to the patient if there
is nothing that I can do for him due to his condition?” Noto
considers that teaching Medical Psychology to medical
students sometimes is similar to teaching someone “to do
nothing”. There, doing nothing can correspond to cathartic
listening, emotional continence, expectant attitude, and
even the use of countertransference in the physician-patient
relationship. A brilliant Brazilian novelist from the later
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19th and early 20th centuries, Machado de Assis, once
wrote: ”…there are things we say better being quiet…”
We all hear that Medicine is both science and art but, in the
last decades, the practice of Medicine is more and more
reflecting an emphasis just on its scientific nature. A
competent physician is not a good mechanic of the human
body but someone who equally combines technical
excellency with being close to their patients, respecting
their dignity, and showing them empathy and compassion.
Evidence-based guidelines containing standards of care are
really of great importance. They allow the organization of a
fragmented physician-patient care model, as different
physicians assisting the same patient at different times can
apply the same objective scientific knowledge. But an
interesting study published in 2016 by Lauren Diamond-
Brown suggested that goals of standardization cannot
rationalize all aspects of medical practice, and policy
makers must not forget the function of a positive physician-
patient relationship. We have to recognize the importance
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of evidence-based medical practice while not forgetting
that the decision-making process of care also involves
important subjective aspects.
Eric Cassel (2012), in his book The Nature of Healing: The
Modern Practice of Medicine, states that “Respect for
persons has helped move the idea of persons and
knowledge about them to a more central position in
medicine. From this it follows that healers and other
clinicians should know as much about persons as they
know about their pathophysiology.” According to him,
almost nothing about people is unaffected by sickness.
Concepts like this one have led to a shift of models of care
from a disease-specific model to patient-centered
collaborative care. Results from reviews of the literature
conducted in 2000 by Mead and Brown and repeated in
2019 by Langberg et al. described five dimensions of a
patient-centered care: sharing power and responsibility,
therapeutic alliance, patient-as-person, coordinated care,
and a biopsychosocial perspective.
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Emanuel and Emanuel (1992) considered – before the
current digital era – that the role of physicians varies, in
different models of physician-patient relationship, from a
guardian to a counsellor or advisor, from a friend or a
teacher to a technical expert. Nevertheless, ethical
considerations about the rights of persons and the
widespread access to information brought by the Internet to
all, have a major impact on the physician-patient
relationship. Medical expertise continues to rely on the
physicians’ knowledge, but the decision-making process
and adoption of a treatment plan now need to include and
respect the patients’ preferred choices.
Taking just diagnostic imaging and individual genetic
tailoring for the treatment of cancers as examples of the
sophisticated progress experienced by Medicine in the last
few decades, as well the development of telemedicine, the
use of artificial intelligence and particularly of social
media, we – physicians – have to learn how to use these
tools for improving the physician-patient relationship and
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not allow them to move us from a focus on the patients
themselves or to create more difficulties in our
communication with them.
Another interesting study, from Hitchsock et al. (2005),
involving primary care patients with multimorbidity,
showed that participants were willing to use technology for
monitoring or educational purposes if it did not preclude
human contact. When listening to patients’ expectations,
humaneness appears as equally or even more important
than medical competence. So, a recommendation of major
importance is that physicians must be focused on building
trust and a strong therapeutic alliance early during the first
visit of a patient.
Last November, the European Council of Medical Orders
supported and adhered to an initiative by the Forum of the
Medical Profession of Spain and the Portuguese Medical
Association to defend and strengthen the physician-patient
relationship by requesting its recognition by UNESCO as
an Intangible Cultural Heritage of Humanity. That proposal
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considers the physician-patient relationship a fundamental
component of health care that can be threatened by
political, social, or economic risks, and technological and
communication changes, which makes it necessary to
protect and enhance the fundamental elements of that
relationship.
Physicians working under difficult circumstances such as
those in Africa, Latin America and Asia, often cannot do
what they consider to be the best plan of action due to the
scarcity of different resources. But they can accomplish at
least partially their mission if they give a little more time
and show empathy and attention to their patients. I am sure
that we can always do better for all if we keep in mind the
reason why we chose to be physicians earlier in our lives:
to help those who are suffering due to their compromised
health.
Finally, I would like to say something about my
background and this moment. My four grandparents arrived
in Brazil in 1912, after fleeing a difficult situation they
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were facing in their mountain villages of Lebanon. My
parents were born in a small city in the interior of the
country and my father became a merchant in his adult life.
When I was studying Medicine, his wish was to see me as a
general surgeon practicing and making my life even in a
deeper part of Brazil, where everything was still waiting to
be built.
But, according to some of my colleagues at the medical
school, I – in a way – declined to be a “real” physician by
choosing to become a psychiatrist. And, in the eyes of
many, the worst part of all: rather than focusing on a money
driven path, I chose to follow an academic career and, early
in my professional life, I engaged in lifelong actions for
enhancing the quality of medical care provided particularly
to those that are more in need.
After so many years, being here today, becoming the 70th
President of the World Medical Association was not
something I ever dreamed of. It gives me great joy and
happiness, even though has not been possible to have some
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of my family members with me at this moment. But, I want
to specially thank them for their continuous and enduring
support.
I am sure that there are times when many of you – like me
now – are participating in professional activities that divert
you from the company of your family. This is a kind of side
effect of being a physician but – remember – as I said
before, a balanced professional and social life is essential
for taking care of others.
So, once again, on behalf of millions of physicians
worldwide and of those they serve, I want to recognize
your efforts and dedication, ultimately aiming to provide
better health to all.
Thank you!
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Before I close this Ceremonial Session of the General
Assembly of the World Medical Association, I give the
microphone to the Secretary General for some
announcements.
On behalf of the World Medical Association, I would like
to thank you for honouring us with your presence here
today.
I now declare this Ceremonial Session closed and invite
you all for a short cocktail provided by the Brazilian
Medical Association just outside this room. Thank you!