ABSTRACT

KEYWORDS

Receiving an award of this nature is of particular importance to me, because I receive it from the INER, the place where I carried out most of my professional life and where I have developed most part of my career. I can say from with great emotion that this institute is my home, and it gives me great pride to be recognized by you; to share this moment with my peers, students and my family, as well as having the opportunity to express some reflections on the current exercise medicine.

Those of us who decide to dedicate our lives to the exercise of medicine take a path that has no return and that never ends; each answer leads us to new questions and in that dialectic we form our medical awareness and our destiny. We are living in times of sudden changes, science shows us amazing leaps, the novelty happens at a great speed and ideas are renewed substantially from one year to the next, and anyone who wants to leave the study and apply only what they already know, in a short time their knowledge will be obsolete. The doctor's preparation is indispensable for us, to reach a shore is always to set off to a new horizon, to a route full of expectations. In our profession having the degree is not enough, the struggle continues, we must study every day, every year and all life. That is why the commitment we make to ourselves, to our profession and to our patients to keep us constantly updated is important. Fortunately, there are continuing medical professional education programs, which we can access voluntarily and which allow us to update skills and knowledge through courses, workshops, congresses, hospital stays, etc., that result in better care for our patients.

Being a doctor implies being a student for life, actively pursuing continuing education, renewing ourselves, being at the forefront of the knowledge that happens every minute in all corners of the world. In the XX century medicine has incorporated important changes; the development of specialities has been one of them. Therefore, the much-needed figure of the general practitioner has been disappearing. One of the characteristics of a good doctor, and this has been observed since ancient times, is being a subject who naturally tends to educate. The classical family doctor of a few decades ago influenced family members with their advice, opinions and sometimes decisions, that were beyond medical matters. Nowadays, it is being rethought to increase their role, even rich countries are considering them as an important need in health services. Undoubtedly, a well-prepared general doctor plays an important role in preventive medicine, they are able to solve most of the cases presented to them and if not, they can refer the specialist to the patients who need a different level of care.

It is becoming increasingly difficult to hear interns talking of the exercise of general medicine as the ultimate goal of their professional preparation. Nowadays, the recently graduated doctor considers that if they are not specialists they will not succeed. Nothing is further from the truth, since we must now recover the key role of the general doctor for the health service of the population. The general doctor must be the cornerstone of health care. In 1958, the teacher Ignacio Chávez said:

"It is true that the specialization brings within it a huge expansive force of progress, responsible for much of the incredible advancement we are witnessing, but it also contains the seed of a regression in the intellectual and spiritual order. Specialization means fragmentation, parcial vision, limited horizon. What is gained in depth, is lost in extension. To dominate a field of knowledge, the rest must be abandoned; the human then confines in on point and sacrifices the integral vision of the science and the universal vision of the world. In this drama the current human of science there is an imminent risk: the dehumanization of medicine and the dehumanization of the doctor".

As we can see, we are bound to keep a balance. Doctors have always cured and relieved the sick, even when the treatment resources were very limited, because the role of the doctor is not limited to curing only with modern methods of diagnosis and treatment. The doctor-patient relationship has two qualities: the necessary attitude of service and the ease of having a relationship with the patient listening to their problems and needs in order to gain their trust. When doctors posses these two qualities, it can be said they have received the gift of healing. Being supportive is also a necessary characteristic, bearing in mind that all the actions we take in our profession must be only motivated by the need to heal, alleviate and comfort the sick. In the oral tradition of our profession it is said that doctors must know how to heal; when this is not possible, they must alleviate suffering and when this is not possible either, they must be able to comfort. In order to do this, is necessary something more than the modern diagnosis methods and the technological advances.

Nowadays, doctor-patient relationship has undergone notorious changes. It is discussed about the medical dehumanization, about large hospitals where patients are numbers, of the despersonalization of medicine, of public institutions and insurance companies that do not allow choosing their doctors, of the lawsuits against doctors for procedures or treatments poorly performed and that force doctors to hire insurance and legal defenses, and we could mention many others. While innovations in technological development applied to medicine have meant breakthrough in diagnosis and treatment, on the other hand, they have transformed medical practice. The tendency to exaggerate the use of technological supports has caused a distance between doctors and patients, the relationship has become cold and distant, and medicine has become excessively expensive.

Working for human health involves very profound aspects that form a medical philosophy and ethics that must always accompany us. Those of us who perform this important task know that the knowledge and skill of which we are capable are not enough. In this struggle for the health of our patients, we must treat them with professionalism, a word that we have heard more and more in recent times and that it is the responsibility that the doctor acquires before society to perform with a conduct that reflects the principles of ethics, humanism, accountability and altruism, based on technically adequate clinical competence to solve the problems that arise. These values must be emphasized and are the basis of the commitment of the medical profession to society.

What is the scenario that we are living in our country?

Some data of the panorama of medical education in Mexico; currently there are 114 schools or faculties of medicine affiliated to the Mexican Association of Faculties and Schools of Medicine (AMFEM); there are approximately 20 more that are not affiliated; there are more than 133 thousand students of medicine, (@secretariadesaludMX), of which they graduate approximately 70%. Mexico has more than 250,000 general doctors, many of them without the possibility of directly exercising their profession and poorly distributed throughout the country.

The scenario of the recently graduated doctor is, in most of cases, to take the exam to enter the residence of the specialty. In 2021, 42,423 people took the exam, 18,173 were selected, which represents an acceptance percentage of 42.2%, compared to 2019 which was 26.4% (www.cifrhs.salud.gob.mx). If we ask ourselves what are the causes of this phenomenon, we can speculate different reasons: 1) did students from one year to the next improve their preparation?; 2) did the degree of difficulty of the exam decrease?; 3) did the minimum grade to pass the test decrease?; 4) did the number of locations increase? The reality is that we have the same teaching staff, the same resources and the same clinical field, so, by increasing the number of places without sufficient infrastructure, the opportunities to comply with university programs become limited and this has an impact on the preparation of students. Despite these adjustments, there are 57.8% of doctors who did not pass, what happens to them?, there is a big discouragement, some of them prepare for the evaluation of the following year, others are frustrated and others accept the challenge of working as general doctors, many of them in the service of pharmacies. A good opportunity for these doctors, who have fresh knowledge and are used to evaluations, is to take the exam to belong to the National Council of General Medicine, regardless they later do a specialization.

Within the framework of the changes in modern medicine since 1963, the creation of the Councils of Medical Specialities was initiated to certify the quality of doctors in professional practice and, at the same time, the recertification every five years in order to keep the doctors updated through continuing medical professional education activities. In 2017, there were 147,910 specialists, of which 69% are certified in 47 Speciality Councils that make up the National Regulatory Council of the Medical Speciality Councils (CONACEM). In the early 1990s, the general doctor did not have a body with these characteristics, so it was not until 1995 that the National Council for General Medicine was stablished. To date, from the 250 thousand general doctors in the country, only 36,323 are certified by the National Council of General Practitioners. The situation of the other thousands of doctors who practise general medicine only after preparation in a medical school with a variable quality of preparation is worrying; they are largely responsible for the first contact care of the sick in this country.

Doctors with many years of practice have had the privilege of being spectators and actors of the great changes that we have had to live in relation to technological advances in diagnosis and treatment. I'm sure when we finished our bachelor's degree and residency, we didn't even dream that we were going to reach the degree of technification in which we are now. In addition, we must consider the great changes in the near future of genetics, stem cells, neurotropics, nanotechnology, just to mention a few.

As we can see, there are many things that come to mind when writing these lines and sharing them; I believe that a ceremony like this forces us to stop along the way and just start thinking, looking in the rearview mirror, analyzing how time has passed and what we have done to give it content and value. In this exercise, thought forces us to ask ourselves what it has meant to be a medical professional in Mexico in the 21st century, how have we approached medicine? Have we thought about medical philosophy? Have we ever raised our science against humanism? In an article entitled "Medical humanism", the teacher Ismael Cosío Villegas, of whom the institute proudly bears his name, said, and I quote:

"Humanism means culture; understanding of man in his aspirations and miseries; appreciation of what is good, what is beautiful and what is just in life; fixing of the norms that govern our inner world, a desire to overcome that leads us, as in the phrase of the philosopher, to equate with life, thought".

The most important and gratifying thing in any profession and human activity that we develop, without a doubt, is to carry it out with joy and passion; to achieve this vocation is indispensable and, in the case of the doctor, this must be a sine qua non; but we must not allow this vocation to be trapped only in the specialism or in the rigor of knowledge and technological advances. Whatever specialty we dedicate ourselves to, it is necessary to have a horizontal gaze, to prepare ourselves in interdisciplinarity and to always keep in mind the humanism that allows us to understand the individual not only as a sick person who has a condition, but as a human equal to us, who suffers, who has dreams and life hopes.

The doctor's preparation is indispensable, to reach a shore is always to set off to a new horizon, to a route full of expectations. n our profession it is not enough to acquire the title, the struggle continues, the study must be of every day, of every year and of all life.

In conclusion, I would like to congratulate and applaud the directors of our institution for their initiative in promoting this kind of recognition, which is a great encouragement to all doctors, whom I invite to continue to fight for the health of our fellow men with pride of belonging to this beloved institution; doing so from the perspective of medical humanism and with all the strength of their vocation.

Thank you.

^‡ Lecture given by Dr. Antonio Soda Merhy in Recognition of Academic Merit Dr. Jaime Villalba Caloca 2022, at the Instituto Nacional de Enfermedades Respiratorias Ismael Cosío Villegas on May 11th, 2022.

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