A recent study has shown that 1 in 4 cardiologists suffer from emotional disturbances, including stress and other psychiatric disorders. Emotional harassment, discrimination, divorce, and age under 55 years were predisposing factors. The international study included 5931 cardiologists interviewed in 2019, covering all continents. Survey respondents represent only 8% of those invited to participate in the survey. The majority were European, White, married, and with children. Individuals at the beginning of their careers were the most affected. Latin America contributed with 17.7% of responses. Men constituted 77.4% of the sample, and women constituted 22.6%. Therefore, it was a select sample that may not represent the entire spectrum of the population of cardiologists. Emotional disturbances were reported by 28% of respondents. There was considerable regional variation, but South America showed the highest rate of psychological disorders, reaching 39.3%; in Asia, the lowest indexes were observed (20.1%). Women were more prone to these disorders, but they also sought psychological help more frequently. This finding corroborates previous research which observed that suicide is more frequent among women doctors than in the general population.

Other researchers had already documented several emotional disorders among physicians, such as anxiety, depression, suicidal ideation, and suicide. ^– For example, recent research in the United States has documented that 42% of cardiologists suffer from burnout, and 83% have some degree of depression. COVID-19 has greatly accentuated these problems. The phenomenon is universal and seems to affect women in particular. These findings are a cause of concern, because they influence the performance of physicians and, therefore, have a direct impact on medical practice.

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Introduction

A.C., a friendly Italian man, received coronary stents 8 years ago and had been feeling well until 3 months ago. He then had progressive breathing difficulty with tightness in his chest. He had loss of appetite and lost 4 kg in that period, but continued to work with good disposition. He had been to two hospital visits, in which he was informed that his lung was normal, based on X-ray. They had not reached final diagnosis, so he came to the office. His general appearance was normal; no abnormality was found on visual inspection. He had normal vital signs; no pallor to suggest anemia. The lungs, heart, abdomen and lower limbs were normal on examination, and resting ECG revealed no abnormalities either. As I palpated his neck, I noticed a mass on the left side. Subsequent examinations proved that a tumor compressed the trachea, which explained his respiratory difficulty. This is a typical example of a case in which only complete clinical examination leads to diagnosis. Telemedicine (TM) would not allow this, as simple inspection did not give any clues, and the clinical history suggested several possibilities, such as heart disease, pulmonary disease, diabetic decompensation, uremia or anemia.

There is now a major debate, both at the health system and at the individual telemedicine level. Telecommunication technologies have long been used in teaching, in science, in the formation of groups for the study of diseases, in the transmission of diagnostic or therapeutic medical procedures, in imaging interpretation by specialists, in teleconference with undisputed efficiency, and will not be considered here. An interesting fact: many even said that, with the Internet, medical conferences would be emptied, because everything could be seen from a distance.

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Beginning in the 1970s and 1980s, the emergence of randomized clinical trials and studies with large cohorts, associated with the development of the methodology for systematic reviews and meta-analyses, triggered a revolution in the way of thinking and performing healthcare practice. Evidence-based medicine (EBM), defined as the integration of the best research evidence with clinical experience and patient values, has become a new paradigm, orienting medical education and specialized publications. One of the principles of EBM was precisely the primacy of information obtained from randomized clinical trials and meta-analyses, which were placed at the top of an evidence hierarchy, valuing quantitative results more than clinical experience and expert opinion. Indeed, it has always been challenging for EBM to integrate empirical evidence with other types of medical knowledge, such as clinical expertise and pathophysiological rationale, or even with the preferences of individual patients.

The use of EBM in clinical practice also runs into the difficulty of finding robust evidence for all subgroups of clinical situations found in the real world, “gray areas” in which no reliable evidence can be obtained from the scientific literature to guide the physician in caring for his patient. Randomized clinical trials are expensive and generally require large study samples and long-term follow-up. There are several situations without evidence, or situations in which the evidence is inconsistent or of poor quality.

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Conclusion

The use of films or film scenes is an important tool to discuss heart conditions, not only regarding the disease’s technical aspects, but also the social, ethical and existential aspects involved in the diagnosis of a severe heart disease. To quote Arthur Kleinman, the laureate films “Manchester by the Sea” and “I, Daniel Blake” are examples that can help us practice medicine in a more sensitive and reflexive, alert and morally responsible way in face of the emotional and experiential challenges presented by the profession.

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