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Points of view

Simulated Patient, neuroscience and Primary Care
Sergio Bernabè FM/GP - Teacher - Tutor - CSeRMEG -Italy 

As stated by WONCAs’ European definition of general practice/family medicine, primary care is the point of first medical contact providing to its users open and unlimited access regardless of age, sex, health problems, religion, culture and income; diseases faced by GPs are usually at a very early stage of development and strongly conditioned by patients’ psychological, linguistic, social, cultural, religious and existential contexts. This means that language and culture have something to do with Medicine and are responsible for the specificity, complexity and uncertainty daily perceived by GPs all over the world.

In this daily entanglement the Family Medicine in the absence of a biological model capable of solving the antinomy Nature/Nurture, claims a specific complexity for its clinical area not shared with other areas of Medicine; and for some of those interested in studying Family Medicine the great challenge seems to be the desire to draw a boundary around the discipline, claiming a unique knowledge base ideally provided of a distinctive set of methods. All this seems suggest a still persistent weakness of the discipline and of some of its research.

A close and careful ethological observation of our daily work shows that relevant symptoms and signs must be recognized first in a stream of words poured throughout the whole consultation. That stream of words must be arranged in a series of motivated events causally connected (as in any narration) to unfold the traits of the clinical plot; and words said must be the expression of shared ideas to set up a senseful and effective narrative structure of the illness. Urged in this cognitive multitasking activity of problem framing GPs usually interrupt patients’ narration after 18 seconds. What happens in those 18 seconds, and also after, while the whole story is rolled out and the medical examination accomplished, is that Language, Culture and cognition, of both patient and doctor, imbues doctors’ clinical judgment and decision making. GPs find themselves in the need to lead with empathy, all along the consultation, the co-construction with patients of a narrative of the perceived illness based on metaphors like the one -for example- suggesting that life needs energy to feed the indispensable ability to cope. The metaphors are narrative tools with the function of bridging the gap between two different worlds of knowledge (the one of the patient and the one of the doctor) aiming to blend together diseases framed by the medical nosography with illnesses perceived by patients in only one solid shared history of sickness, acceptable, by the way, by the social network in which they both live (e.g. by allowing a paid sick leave). The observation of our daily clinical work shows that the consultation and the underlying clinical reasoning can be described also as a social event based on negotiation: the patient knows (perceives) his illness, the doctor knows (has studied) the diseases, through the negotiation of the turning points of the plot of the story they are talking about, doctor and patient come to co-construct a shared clinical history and, finally, a shared diagnosis of sickness. This narrative procedure for its being ‘naturally and juridically shared' incorporates the true consent of patients and it's for this that is possible to state that (at the end of the consultation) the person that decided to consult the doctor could be or is really sick; to issue for this reason a sick leave and/or obtain that the patient accepts to undergo an exam or to start and adhere to a therapy even if burdened with relevant side effects: an effective and legally valid oral contract.

But, as already stated before, this social event, started by the patients’ will to consult the doctor, is carried on by two interacting and embodied consciousness; both characterized by volitions, sensations, emotions, aims, and thoughts. In other words what happens during that social event is that the neurophysiology of consciousness  (both of the patient and the doctor) reveals, through language, the high level functions of the human brain that give rise to what proves to be also a process of social cognition. Neurosciences have already heaped a huge amount of knowledge on social cognition and neurophysiology of consciousness and its development, from the gastrulating embryo onward.

Here it seems important to focus the reader's attention to a research area of neuroscience that has proved to be particularly interesting and fruitful: the one opened by the discovery of mirror neurons (Rizzolatti). Mirror neurons, and more generally the premotor cortex, in fact, seem to play a prominent role not only in learning and implementation of motor actions but also in understanding the actions and intentions of others, and also in the language.

All this through a mechanism of embodied simulation.

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