ABC | Volume 112, Nº4, April 2019

Viewpoint Window to the Future or Door to Chaos? Marcelo Antônio Cartaxo Queiroga Lopes, 1 Gláucia Maria Moraes de Oliveira, 2 Alberto Amaral Júnior, 3 Eitel Santiago de Brito Pereira 4 Hospital Metropolitano Dom José Maria Pires, 1 João Pessoa, PB – Brazil Universidade Federal do Rio de Janeiro, 2 Rio de Janeiro, RJ – Brazil Universidade de São Paulo, 3 São Paulo, SP – Brazil Universidade Federal da Paraíba, 4 João Pessoa, PB – Brazil Mailing Address: Marcelo Antônio Cartaxo Queiroga Lopes • Cardiocenter – Av. Ministro José Américo de Almeida, 1450, Torre, Hospital Alberto Urquiza Wanderley. Postal Code 58.040-300, João Pessoa, PB – Brazil E-mail: mqueiroga@cardiol.br , marcelocartaxoqueiroga@gmail.com Manuscript received February 19, 2019, revised manuscript February 19, 2019, accepted February 19, 2019 Keywords Medicine/trends;National Science, Technology and Innovation Policy; Technological Development/ethic; Telemedicine/ legislation & jurisprudence; Delivery Health Care/legislation & jurisprudence; Precision Medicine/trends. DOI: 10.5935/abc.20190056 The remarkable advance in technology has caused a new social revolution impacting all areas of knowledge, modifying traditions and practices that were consecrated centuries ago. Advances in informatics and telecommunications with practical application in various sciences are eloquent examples of such transformation. 1 In medicine, this progress has brought up extraordinary advances in diagnosis and therapy, since the combination of newmedical technologies and efficient communication media has bequeathed us telemedicine, which has been practiced for more than two decades with great success, opening the doors for solutions such as a telematic transmission of a simple electrocardiogram to remotely performing robotic surgeries. 2 In this scenario, the need for regulation of telemedicine in Brazil arose. The Brazilian federal legislation handed over such attribution to the Federal Medical Council ( Conselho Federal de Medicina , CFM), which performed it by issuing CFM Resolution 2.227/2018, 3 already published in the Union Official Gazette ( Diário Oficial da União ). In the aforementioned resolution, CFM defined in Article 1 telemedicine as "the practice of medicine mediated by technologies for assistance, education, research, prevention of diseases and injuries, and health promotion." The Council is fully aware of possible benefits that can result of an ethical application of this practice, which can broaden access to public health and maximize the effects of already established public policies. That was why the Council issued the regulations, but it must be aware of the disruptive power of this technology, which confronts, in theory, millennial postulates of professional practice. Medicine, as conceived, does not dispense with physician-patient interaction. Therefore, telemedicine cannot dispense the doctor or replace him with another professional in the practice of those acts that, under the terms of Law 12.842/2013, 4 are exclusively to physicians. The CFM uses the term teleconsultation as a shelter of telemedicine. The word sounds like a situation where a name comes to have a life of its own as something justifiable, routine, as if it had always existed and dispensed a critical analysis of its origins. However, novelty should not be understood in this way. There are challenges of a technical, ethical, legal, regulatory, and cultural nature regarding teleconsultation, which is exclusive of the physician and requires access to medical records, or in other words, to the set of standardized and ordered documents that the patient might have from a previous care. It is important to emphasize that access to medical record is among the exclusive acts of the physician and the patient has the right to demand that the data recorded are kept secret. 5 Classically, a consultation includes the triad anamnesis, physical examination, and complementary tests in an integrated and "carousel" dynamic. Thus, physical examination findings, for example, may motivate a return to anamnesis; the image reports, in turn, can determine the making of another physical examination, etc. Who decides this dynamic is traditionally the doctor, who assumes responsibility for his decisions. Now, the teleconsultation can make the physical examination unfeasible, since the doctor will be away from the patient. In this case, who will take responsibility? Will the doctor sitting in front of a computer have a duty to raise an objection of conscience not to proceed? Nowadays, even in well-known cases, prudence – a cornerstone of ethics – suggests that a face-to-face interaction is needed in most cases. 5 Would the patient be well informed that the teleconsultation and any other methods of telemedicine may represent an incomplete methodology, especially if they involve the waiver or substitution of an actual physician by another type of professional? Would the patient take responsibility for any failures resulting from this new form of assistance and still give consent? Would the lack of a detailed anamnesis, such as those commonly done in traditional consultations, or the shortage of documentary records, not weaken the acts of telemedicine? Incidentally, by documentary evidence, the role of the medical record as a memory, or thread leading to an efficient diagnosis, has the potential to be impaired in the inadequate practice of telemedicine procedures, which can be damaging. CFM regulation should therefore represent a step forward, not a setback. Broadening access in public health is a common desire of all physicians. In this nuance, telemedicine brings indisputable progress, which justifies its regulation. However, CFM should be vigilant so that everything is done properly, with technical quality discretion, anticipating the regulatory impact of the standard. Regulation should preserve, for example, the millenary postulates of the practice of medicine and promote equality. The major challenge of CFM Resolution 2.227/2018 3 is to be effective and applicable in the advance of social justice and deliberative ethics. 461