Olvido de los fenómenos psicológicos en la relación médico-paciente anciano (página 2)

RESULTADOS

La búsqueda inicial produjo 424 artículos. No se tuvieron en cuenta 367 porque no incluían pacientes ancianos o no eran estudios de investigación. Así, pues, se trabajó con 57 artículos.

Una proporción considerable de los artículos de investigación 19 (33%), se referían a las actitudes14-32; 14 (25%) a los resultados de la relación33-46; y 13 (23%) a los patrones de comunicación47-59. Algunos pocos 9 (16%), trataban con asuntos éticos60-68 y una cantidad mínima 2 (3%), con los fenómenos psicológicos de la relación médico-paciente anciano69,70.

DISCUSION

El encuentro entre el médico y el anciano tiene varios factores que intervienen en el desarrollo de una relación profesional adecuada o inadecuada.

Las actitudes, estereotipos o mitos en ambos protagonistas, médico y anciano, pueden afectar este encuentro. La gerofobia por parte del médico, o las falsas creencias acerca de la enfermedad en el paciente, también lo pueden alterar. Asimismo puede haber barreras culturales que afectan la relación. En cambio, por lo general, las actitudes positivas la facilitan2,3,5,6,14-32.

Para entender la dinámica de la relación médico-paciente anciano, se necesita un conocimiento más específico acerca de los fenómenos psicológicos entre el médico y el anciano. En esta relación humana y profesional hay respuestas emocionales bilaterales conscientes o inconscientes que pueden facilitar o entorpecer su desarrollo. Los fenómenos psicológicos descritos son la transferencia, la contratransferencia, el "rapport," la empatía, y la resistencia. Las contratransferencias son las reacciones emocionales del médico hacia el paciente anciano, como sentimientos (frustración) y conductas (rudeza, acortamiento del encuentro). Cuando el médico no reconoce esta clase de respuestas, afectan en gran forma su relación con los pacientes. Las transferencias son las emociones del paciente anciano hacia el médico (sentimientos positivos o negativos). La empatía es la habilidad del médico para recibir y decodificar la comunicación afectiva de su paciente anciano, ello puede permitir el entendimiento de los sentimientos del paciente. El "rapport" incluye el estado de mutua confianza y respeto entre el médico y el paciente anciano. Las resistencias son las reacciones del paciente anciano en contra de la relación con el médico o del tratamiento. Por último, el entendimiento de estos fenómenos psicológicos es esencial para una adecuada relación profesional con los ancianos2,3,5,6,10,11,69,70.

La comunicación entre el médico y el anciano es compleja. Incluye la comunicación verbal y el lenguaje no-verbal. Se necesitan habilidades relacionales, verbales y sobre todo no-verbales por parte del médico. Un número importante de ancianos tiene dificultades auditivas, visuales, o del habla que conducen a estrategias especiales para comunicarse con ellos2,7,12,47-59.

En las decisiones clínicas con los ancianos se presentan dilemas éticos. Los mayores dilemas tienen que ver con las medidas para tratamientos de sostén de la vida o en pacientes terminales. En esto es preferible comprometer al mismo paciente, cuando es posible, y a la familia o a sus representantes legales60-68.

Los resultados definitivos del encuentro se pueden reflejar en la satisfacción por parte del médico o del paciente, en el seguimiento del paciente, y en el cumplimiento o no por parte del anciano de la terapia que recomienda el médico2,33-46.

Para terminar, la relación médico paciente anciano se ha estudiado poco, y sus fenómenos psicológicos se entienden todavía menos. Se necesitan más trabajos investigativos en esta área para poder clarificar esas relaciones tan importantes y así poder mejorar su calidad.

SUMMARY

To assess publications on the physician-aged patient relationship, we searched MEDLINE (1966-1995) and made a systematic review of publications. We looked for research articles related to the components of the physician-aged patient relationship. Of the 57 articles that were included, 33% focused on attitudinal barriers, 25% on out-comes, 23% on communication skills, 16% on ethical issues, and only 3% on psychological phenomena. These phenomena such as transference, countertransference, and empathy are essential to understand the physician-aged patient relationship. We concluded that the psychological phenomena between physicians and their aged patients are often not included in research.

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Carlos A. Reyes-Ortiz, M. D. 2, Sylvia Gheorghiu, M. D. 2, Thomas Mulligan, M. D. 3 1. Trabajo presentado en el Congreso Anual de la Sociedad Americana de Geriatría, en Chicago, Illinois, EE. UU. , mayo de 1996. 2. Fellows in Geriatric Medicine. Department of Internal Medicine, Medical College of Virginia, Virginia Commonwealth University, Richmond. 3. Chief, Geriatrics Section, Department of Internal Medicine, Medical College of Virginia, Virginia Commonwealth University, and Hunter Holmes McGuire Veterans Affairs Medical Center, Richmond, Virginia, EE. UU.