ABC | Volume 112, Nº4, April 2019

Viewpoint Lopes et al Window to the future or door to chaos? Arq Bras Cardiol. 2019; 112(4):461-465 Paragraph 3 of the same Article 4 of the aforementioned resolution allows the "establishment of a virtual doctor-patient relationship" only for health care coverage in geographically remote areas, provided that there are the recommended physical and technical conditions, as well as healthcare professionals. The argument that teleconsulting fulfills the difficulty of healthcare assistance due to geographic distance requires clarification of the meaning of distance, so that it does not fit something that can be face-to-face, but that presents difficulties of access, for being far, for having complicated transit, for demanding assistance at times incompatible with the availability of the physician, etc. In short, comfort should not serve as justification for the acceptance of an incomplete care from the point of view of identification of signs and symptoms. It is clear that the new rule has yet to define the meaning of geographically remote areas, leaving room for broader interpretations of the possibilities of the teleconsultation, which cannot lose its merely complementary character, to meet the needs of the assistance of a country of continental dimensions, transforming itself into powerful tool for curtailing patients' rights. That is, teleconsulting, assuming its legality, is only justified to expand access to unserved beneficiaries of the SUS. On the other hand, in the scope of Supplementary Health, Law 9.656, dated June 3, 1998, 10 which provides for private healthcare plans and insurance, establishes a specific regulatory framework, provided for in the contractual sphere, distinct from the commitment to universal access, provided for in Article 196 of the Federal Constitution. Therefore, the coverage limits of the beneficiaries of the health plan operators are clearly defined by law. The National Agency of Supplementary Health ( Agência Nacional de Saúde Suplementar , ANS), which is responsible for regulating the sector and elaborating the Role of Procedures and Events in Health, or Role of Procedures, has already decided that medical consultation is one of the compulsory coverage procedures. Also, teleconsultation could not be used to replace the essential face-to-face consultation, which the beneficiary is totally burdened with, to be used to restrict access to the clear legal right. Still resorting to Law 7.498/1986, 9 it is clear that the nurse only has legal competence to prescribe "medications established in public health programs and routinely approved by the health institution." Thus, even if it is alleged that the responsibility for the eventual prescription in teleconsultation is of the doctor who is at a distance, the other health professional who also attends the medical act, also participates, in full exercise of his profession, therefore, must behave within the legal limits of the law. It seems that, in the scope of supplementary health, there is no legal support, for example, for nurses, even under supervision, to prescribe medications or request tests, and the realization of a teleconsultation, with the participation of other health professionals, would be a practice without support in the legislation. 10 The publication of Resolution 2.227/2018 3 caused uneasiness, since it is necessary to start from a premise: teleconsultation can only be done when the doctor already knows the patient. Necessary, therefore, a prior consultation in which there was a previous face-to-face relation between doctor and patient. However, the presence of this requirement will be difficult to control and oversight, because knowing the patient does not mean knowing the case of the moment. Thus, first-time consultations of the clinical situation are likely to be "confused" with a follow-up consultation, where one could accept the non-presence for information about progression, therapeutic adjustments, and evaluation of the requested tests. Law 12.871, of October 22, 2013, 11 which established the Mais Médicos Program, allowed the revalidation of the medical diploma not to be compulsory in the strict context of this program. That is, Resolution 2.227/2018 3 should make it clear that only in the context of public programs, once the absence of doctors is verified, it would be possible to teleconsult without another doctor with the patient. It is believed that Hippocrates removed medicine from the gods exactly to allow interaction between humans. We now run the risk of the "deification" of technology to extrapolate its undeniable utility of data transmission within ethical standards. Thus, from the transdisciplinary point of view, about its three foundations – rigor, openness, and tolerance – there is a high risk of compromising technoscientific rigor. 5 The CFM, when editing the Resolution, embraces the unknown, the unexpected, disregarding the tolerance of opposing opinions, which may arise in the complex process of decision making, in the face of the patient's right to the active voice, when he dialogues directly with the doctor. Concerning the two important pillars of medical ethics, it is a matter of concern to deal with prudence – caution during the decision-making process – and with zeal – quality of application and observance of the evolution of consensual conduct. Concerning three of the principles of bioethics, it concerns the management of beneficence as well as non‑maleficence – that today, because any method is liable to cause harm, has become synonymous with security, in addition to bringing new aspects about autonomy. 5 Finally, does the teleconsultation pass through the sieve of the ten steps 12 essential for a qualified clinical diagnosis in the context of anamnesis-physical examination integration? It is worth remembering the decalogue that must be observed in order to prepare a good diagnosis: (1) an overall view of the patient made possible by physical proximity; (2) patient's free issue of his complaints and impressions; (3) physician-patient dialogue stimulated to clarify obscure points and hypotheses raised by the physician based on what the patient said; (4) construction of diagnostic hypotheses supported by anamnesis; (5) performing the physical examination and identifying, or not, signs aligned with the hypotheses, or expanding to new hypotheses; (6) return to anamnesis when indicated by physical examination findings that compose new clinical reasoning; (7) evaluation of the need and selection of complementary examination based on anamnesis-physical examination integration; (8) integration of the reports of complementary tests with the clinical reasoning sustaining the request of the tests; (9) formulation of the probable diagnosis; and (10) use as a basis for therapeutic conduct, always remembering to clarify the patient well so 463