The editorial deals with the problem of the relationship between the doctor and the patient, in its present evolution: From the impatient Doctor to the Patient-Docto

Tolone, Oreste

Annali dell'Istituto Superiore di Sanità

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Ann Ist Super Sanità 2019 | Vol. 55, No. 1: 1-2
DOI: 10.4415/ANN_19_01_01
Editorial
From the impatient doctor  
to the patient-doctor
Oreste Tolone
Dipartimento di Scienze Filosofiche, Pedagogiche ed Economico-Quantitative,  
Università degli Studi “Gabriele D’Annunzio”, Chieti-Pescara, Italy
Over the last century, we have witnessed the trans-
formation of the paternalistic doctor-patient relational 
model – which had characterized the existence of medi-
cine in its first two millennia of activity – into a shared 
model. A model, that is centred on the patient (patient 
centred medicine), and no longer on the disease (disease 
centred medicine) [1-4] – as Ludolf Krehl and Viktor von 
Weizsäcker had already argued at the beginning of the 
20th century [5, 6]; a model based on the recognition, 
to the actors, of equal powers and responsibilities. The 
shared model, which inaugurates a form of new thera-
peutic alliance between doctor and patient, risks, how-
ever, to assume, within a health apparatus that moves 
in the triangulation economy/technology/politics [7], 
the appearance of a pact, of a contract, which hides a 
model of defensive medicine (information model). The 
practices of informed consent [8, 9], if on the one hand 
have represented a way to make the patient aware and 
responsible for therapeutic choices, on the other hand 
they channel the doctor-patient relationship through 
the tracks of the formal, legal and contractual relation-
ship. An all-out information hides, in fact, an autonomist 
model [10], in which it is fundamental to inform, not 
to communicate. This transfer of communication pro-
cedures that are valid among strangers, to the intimate 
and trustworthy dimension [11], determines a passage 
not so much to good medicine, but to safe medicine. 
Distrust, however, reigns in it. 
The increase in disputes, malpractices and attacks 
against doctors (according to the Federation of Asso-
ciations of Doctors, 1420 only in 2017 in Italy) [12] is 
a sign of an epoch-making crisis: the end of a hierarchi-
cal, paternalistic relationship and the need for a new 
hierarchy to be negotiated. This reconsideration of roles 
and functions puts both the doctor and the patient in 
crisis, both of whom are now forced to reconsider their 
own and other people’s roles. The loss of an exclusive 
top position on the part of the doctor, and the need for 
a continuous (sometimes exhausting) coming to terms 
with the patient, can induce the doctor to retreat in the 
name of scientific knowledge and of objective knowl-
edge. This attempt to recover the summit, bypassing 
the relational need of the therapeutic alliance, feeds the 
figure of an “impatient doctor”, not very inclined to ne-
gotiate. On the other hand, the sick person appears to 
be increasingly freed from a privileged relationship; in 
particular, the growing specialization and technologiza-
tion of medicine, the affirmation of a business model 
of care, a nomadism which makes the patient itinerant, 
in search of the best services where they are offered, 
the interference of the mass media (which heavily affects 
the communication between doctor and patient) [13], 
interrupt the bond of trust. The “patient-doctor”, who 
knows, who undermines the authority of the doctor 
and of medicine, who proposes the various therapeutic 
options, in fact overturns the traditional paternalistic 
model into an extreme autonomous model. 
However, this overturning seems to duplicate rather 
than undo the error of perspective of paternalism; it is 
rebutted to subject with subject, to preeminence with 
preeminence, to hegemony with hegemony. With the 
difference that, in an age of “moral foreigners” [14] the 
primacy seems to belong to the freedom (of the pa-
tient), rather than to the truth. 
This difficulty in re-establishing a new balance be-
tween the protagonists has its philosophical roots in 
modernity and in the subject/object separation it en-
tails. Both these options (impatient doctor and patient-
doctor), in fact, are based on a hard, drastic reading 
of modern subjectivity. The Evidence-Based Medicine 
revolution has as its premise the Cartesian dualism 
between res extensa and res cogitans, the experimental 
method, specialization, a certain form of reductionism, 
the distance from one’s own research object, which in 
medicine becomes “therapeutic distance”. This brings 
with it, in addition to immeasurable benefits, the risk of 
a “removal of the patient” [15, 16]. 
This is even more evident with the advent of tech-
nology, that is, with the affirmation of the indissoluble 
union between science and technology. As Hans Jonas 
clearly pointed out in his Technique, Medicine and Eth-
ics, the exponential development of technology over 
the last century has brought about a qualitative leap: 
once something becomes technically possible, feasible, 
it is inevitable that it will be done [17]. Action, in other 
words, is no longer dictated by the object in front of us, 
but by action itself as “feasible”. However, to the doctor 
«the purpose is given by the internal purpose of its ob-
ject, the “raw material” is already the last and the whole, 
that is the patient, and the doctor must identify himself 
Oreste Tolone
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with the purpose proper to the latter» [18]. This submis-
sion of the object (the patient) to the technician (the 
doctor) has considerable repercussions on the medicine: 
the patient and the anthropological dimension of the 
relationship and of the care are lost, or completely over-
shadowed. This, however, means forgetting the deeply 
dialogical dimension of medicine [19]. In fact, it is born 
keeping together the need for healing with the need for 
care, the need for a therapeutic distance with that of 
a humanitarian ethos [20, 21]. The seduction of the tech-
nique, instead, has traced a deep furrow, whose effects 
are tangible in the changed relationship between doctor 
and patient. On the one hand, there is the need to re-
cover a relationship of trust with the patient, of esteem, 
which, however, is mainly established by virtue of taking 
care, of taking charge of the sick man, even and in par-
ticular in chronic diseases, in unfortunate events; on the 
other hand, the union between science and technology 
feeds the opposite tendency, to remove from the priority 
tasks of the doctor precisely these functions [22]. Usu-
ally delegated to third parties. 
This short circuit risks stiffening the doctor/patient re-
lationship in a relationship between self-sufficient sub-
jects, who claim their rights (to know and to decide). On 
the contrary, medical anthropology, medical humanities, 
narrative medicine, each from its own specific perspec-
tive, move precisely in the attempt to recover the dialogi-
cal dimension of medicine. This does not mean limiting 
the rights of the doctor by claiming those of the patient 
(which is closer to the war of position, to the “role play”), 
but promoting a circular hierarchy, in which the recovery 
of a «logic of care» by the doctor plays an essential part. 
A medicine that cures, that does not renounce to being 
medical art [23], does not put aside the clothes of sci-
ence, but guarantees, even in an age of hyper-subjects, 
an open confrontation between doctor and patient.
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From the impatient doctor to the patient-doctor

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From the impatient doctor to the patient-doctor

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