30 de abril de 2013

Dr Horacio Vogelfang: subtitulados

www.citaenlasdiagonales.com.arDr Horacio Vogelfang: Vocaciones.

Citas, a la vuelta con Carlos Gianni.

Amigos esta es una nueva sección la cual la comenzamos recreando alguito de la enorme obra de Carlos Gianni.
Queremos agradecerle su Generosidad y Confianza.

Acerca de Carlos:

Docente, compositor, productor y director musical de exitosas obras (Huesito Caracú, Vivitos y Coleando, Narices y La vuelta a la manzana, entre otras), que junto a Hugo Midón, obtuvieron en reiteradas oportunidades el premio ACE. Participa también como compositor y director, en distintos programas de televisión. Dicta conferencias, cursos y seminarios tanto en el interior como en el exterior de país.
Músico de reconocida trayectoria en el ámbito del Teatro Musical, que en varias ocasiones ha compartido la autoría de espectáculos con Hugo Midón.

Actualmente, además de volver a presentar No sé qué decir en el Teatro De La Comedia, participa como compositor y director musical en Derechos Torcidos (Sala Picasso del Complejo Teatral La Plaza).

Es compositor además, de Huesito Caracú, La Familia Fernandes, Locos Recuerdos y Vivitos y Coleando, entre otros.

Ultimamente, ha llevado el tema de la improvisación musical a un alto nivel académico, siendo invitado a cerrar la XXVI Conferencia de la I.S.M.E. (Internacional Society for Music Education) en Tenerife, España, con un trabajo de improvisación grupal en la Sesión Plenaria.

Ha colaborado en numerosas publicaciones, y su tarea tanto en la docencia como en el campo de la música ha sido reconocida por la crítica en la Argentina y en el exterior.

Dr Alberto Rancati en Inglés

Dr Alberto Rancatti: “From a Surgeon Father to Adolescent Trauma” (1/3)Dr Alberto Rancati: Dr Alberto Rancati entrevista en inglés.

SH: Today in Cita en las Diagonales we have Dr Alberto Rancatti, surgeon, oncologist, breast reconstruction specialist, with a firm story with his vocation for Medicine. You studied at Hospital de Clínicas, right?
AR: yes. I did my residency as a General Surgeon, there, and also, plastic surgery. So, all my studies were there.
SH: Alberto, we were discussing with Tomás how to begin this interview, in order to search the construction of your vocation. And we thought about beginning with something we never ask this way: how was your relationship with doctors when you were a child?
AR: I had a family history related to Medicine. My father is a surgeon, still working at 86 years old, with me. And I never thought about other profession. As a child I travelled with him. I anxiously waited every weekend to go travelling with him. I went with him, went to the clinic, entered the OR.
SH: How old were you Alberto?
AR: Eight, nine, ten years old. In La Pampa he had a group of doctors he worked with and their children, who turned out to be all doctors, friends today. So, I always wanted to be a doctor.
SH: And at that age, what was for you Medicine, to be a doctor? What did you see about your dad that interested you?
AR: The nearest thing to Medicine is that we went hunting and what we hunted, we healed. When we finished hunting, we tried to “operate” those animals to take the projectiles out and heal them. And we checked on them after a week. So they worked at the clinic, and we went hunting. And if a bird or something was hurt, we picked it up and heal it, as we could. And we asked for advice, like a game. Today when I talk about it, people find it sinister –go hunting to heal-.
SH: So the goal was to hunt in order to kill?
AR: No, no. The goal was to hunt and have fun, like any kid that age, but when we could “repair” something we did it.
SH: And when you were younger than eight years old? What games did you play?
AR: I played the doctor too! For Christmas they gave me medical stuff. And I asked for them. Really, if I think back, it was medicine and technology. Back then, there were some electric machines... I was interest in state-of-the-art machines in Medicine. And it kept throughout time.
SH: When you began Medicine, did you have in mind to become a surgeon?
AR: Yes. I wasn’t sure about the field, but I wanted surgery. When I was fifteen years old I had surgery due to an injury in my arm. And I remember my father’s fear when we had the diagnosis: melanoma. I think that had to do with my choices.
SH: With the melanoma? Why?
AR: I remember my father’s fear and the surgery... when you live a traumatic experience like that, I think it brands you. And one of the specialties I followed, even going to Italy to live to study it, was that –melanoma-. What I had lived, with fears, in my adolescence.
SH: You studied breast in Italy. Was that later?
AR: Yes. Later, I went to the National Cancer Institute of Milan, with a scholarship from the International Union Against Cancer, and I went to study, first melanoma, and when I was there, I met Dr Veronesi, a world renown oncologist, who changed the story of mastectomies. And I went from oncological breast surgery, to plastic breast surgery. And later, to a new specialization: oncoplastic surgery, which combines plastic surgery and oncological surgery, in order to get the best aesthetic result, with the best medical result. You don’t have to mutilate in order to cure. And I think that’s the future in the treatment of oncological diseases. We are more and more aware that oncological surgery can include immediate reconstruction -at the same time the surgery is being done. The patient doesn’t have to experience the mutilation in order to value the reconstruction.

Dr Alberto Rancatti: “Before, during, and after the OR” (2/3)
SH: What goes through your mind at that time? What do you think, as a doctor who also takes care of the harmony of the body?
AR: It’s very comforting. It’s an activity where the patients value very much what it does: give them back their harmony, allow them to recognise themselves in the mirror. After the surgery there is a lot of fear: fear of death, of being deformed… Another of the many fears before surgery. When the patient is aware of this possibility, he enters the OR with a sort of tranquillity. And after the surgery they value all that greatly, and it is very rewarding. During surgery you know that you are giving the patient the best, both regarding the oncological side, and the cosmetic side. Today you have a lot of possibilities, and you have to “match” the patients with what you’re going to do. The planning stage before surgery is everything. The surgery is the execution of your plan, taking into account all the variables that exist, but today you can foresee the results, thanks to the different implants, materials, sizes, and you can show it to the patient. That helps them a lot. Last year, I participated as faculty at University of California San Diego, at the “Center for the Future of Surgery”, a simulation and training facility, where we have an area, of 23 ORs, and there we aim to improve the education of the doctors, so their learning curve is not with the patients. That was our situation. You had a teacher that taught as you were operating on a patient. Today you can perform a full surgery on a human like dummy. Students at UC have to practice on this dummy before entering the OR.
SH: How long does that practice take?
AR: As long as it is needed. They’re debriefed, they see the surgery, they perform it on the dummy and if there are any mistakes they stop and correct it. Much like a pilot –they won’t fly for the first time during a battle-. No one will step on a plane if the pilot hasn’t practised on a simulator first. Well, with surgeries it is the same.
SH: And what do you do there?
AR: I train the Latin-American doctors, and for the doctors at UC, regarding plastic surgery, I’m a director at the centre for simulation and training. We created what we call the “masto-trainer”, a thorax with different sized breasts, injuries, where you can do different kind of practices. It even bleeds. You can have different degrees of difficulty. Part of the training is a mastectomy and breast reconstruction, in order to improve their techniques, without the patient suffering the doctor’s learning curve.
It was inaugurated a year ago. And 550 coursed have been done already. For different specializations, not only plastic surgery. And we are now trying to bring that to Latin America. Today, many private companies support this. Companies who make the surgical instruments; they provide us with these instruments, and can have doctors training. It’s a win-win situation: for the companies, the doctors, and above all, the patients. They are cared for by doctors who have been trained.              
SH: There’s is something I haven’t asked yet. Why breast?
AR: Breast surgery is the combination of the oncological and the aesthetic. For women, is the most frequent pathology. One out of eight women will have breast cancer. One out of four people will have an oncological pathology. And also, the breast is an icon. And my training was regarding the breast, with Veronesi, who argued about removing the breast when you can just remove a section a have a good aesthetic result. It’s the same result. So, you start thinking in having good results, keeping also the feminine shape. And that works also for head and neck and other areas where you can aesthetically improve the results. But the breasts are, for women, one of the areas most valued, and also, most plagued by cancer. One has to evaluate what one is good for. And I think I have more abilities in this area than in others, it felt more comfortable. And it ended up being something I enjoy.

Dr Alberto Rancatti: “Of Tastes, Of Time, Of Doctor´s Analysis.” (3/3)

SH: Something that caught my attention, that I thought beautiful, is the bond you have with your father in the OR.
AR: Yes, I started helping him, and now he helps me. He’s 86 years old. And every morning I pick him up and we go together to work. We have breakfast, we discuss patients, surgeries. That’s one of the benefits when you share, you choose the same profession. It could be the other way, we could be competitive with each other, there could be bad feelings, but luckily, it’s not so.
When you enjoy what you do, time flies. I don’t get tired working all day. People think that working a lot of hours is exhausting, but I can’t wait to get into the OR every morning and start working. I think it’s a privilege to do something you like. I think it goes hand in hand with liking what you do, and you even don’t care much for the “economic result”.
AR: I think that vocation and dedication don’t allow for that interest. Of course, we all want to live well, be well paid, but it’s a mistake to make that your goal, foregoing what you like. First you have to think what abilities you posses, and what you enjoy doing. That is what you have to do. If you do what you like, with passion, with dedication, investing time, doing things in relation to that, and if it’s real, and people perceive that, you will get paid for it.  People want to feel that you care for them, that you love what you do, in Medicine at least. Sometimes it’s hard to transmit that to people who are just starting. There’s so much competition... everybody wants success now, money now... and there you can lose your vocation. Everything takes time. It’s wrong to think that if you are successful you’ll have patients, no; you have patients and then comes success. It’s hard to transmit that. People want things now
AR: My son it’s about to start Medicine School. And though there are a lot of doctors and a lot of awful situations, I think that people who start and do things right have many opportunities. They will stand out. If they do things right, they will stand out, because very few do things right. And you can see that. If they keep in mind that they have to do that effort... You can perceive that. To transmit security, confidence... you can’t fake that. You see it.  And I think that those who train and improve themselves will have the key. People want the same things: a doctor who takes care of them, who is well trained, who is available, who is affectionate.
TH: If you want to, please tell us what therapy did for you... Do you go to therapy?
AR: My wife is a psychoanalyst. And I think that there’s a breaking point with therapy: the results are more enjoyable for others than for me! Once you have the tools that psychoanalysis gives you, one can establish a better relationship with what surrounds you. You learn why you do certain things and why you do things in a certain way. It gave me tools to improve relationships and to understand one’s identity, the why. There was a moment I was so excited that I had therapy three or four times a week. A very interesting intellectual exercise. If you don’t try it, you can’t imagine it. You can really understand it when you go through that experience. And many things that you learn, that you incorporate, stay with you all the time.
AR: Today I’m more in touch with that, with common sense, in order to decide to do something or not. And if I have to give myself to a psychoanalyst, which is something heavy, it’s like letting yourself be cut open by a surgeon. I’d like to know... Sometimes I realise when a patient comes, it’s not I who does the interview... they interview me. They’re checking if they will trust in me for the surgery. It’s the same thing. In the first sessions you interview the psychoanalyst.Cita en las Diagonales

29 de abril de 2013

El impasse del psiquiatra en la época de la epidemia de las clasificaciones por Silvia Baudini

El impasse del psiquiatra en la época de la epidemia de las clasificaciones
Silvia Baudini
“Esta psiquiatría generalizada –por oposición a la restringida de antaño-, que está desacomplejada de su ignorancia, y emancipada de los muros del asilo, porta el nombre de salud mental y ya funciona sin los psiquiatras.”*
En el “Breve discurso a los psiquiatras”(1), Lacan se pregunta y le pregunta a los participantes, qué espera un psiquiatra del psicoanálisis. Discurso de 1967, el mismo año de su Proposición sobre el pase. Descarta dos razones, la primera: comprender al paciente, la segunda, tratar la angustia que el paciente le provoca. Finalmente da la tercera razón, única válida para Lacan: ocuparse del loco del que nos dice que tiene el objeto en el bolsillo y las consecuencias que podría extraer de dicha posición del psicótico.
¿Qué podemos decir de la época? Se han unido dos discursos, el científico y el capitalista, ambos han tomado la delantera en todos los campos. Y desde hace un tiempo dominan el destino humano. Desde la biotecnología, pasando por el mundo virtualizado del dinero, hasta el lugar del trabajador todo queda sometido a sus leyes.
El objeto a ha subido al cenit y cada uno puede tenerlo en el bolsillo, entonces la dimensión del fantasma como la elucubración, el semblante que hace pasar la pulsión por el campo del Otro para alcanzar el objeto, - que como dice Lacan es la “verdadera naturaleza del lazo que existe para este ser que llamamos dentro de la norma”, oponiéndolo así a la psicosis - se diluye como efecto de la acción de los dos discursos arriba mencionados. Se produce, señala Lacan, un borramiento de las fronteras, de las jerarquías de los grados: “los objetos a cabalgan por todas partes, aislados, solos y siempre listos para apresarlos a ustedes a la vuelta de la esquina”. Miradas y voces que nos rodean sin otro soporte que lo que la ciencia produce y que se reproduce gracias a una tecnología al servicio del mercado.
Entonces, el mundo absoluto de la ciencia físico-matemática se volvió un mundo relativo de porcentajes, la biología solo nos da porcentajes y nos augura un mundo cada vez más pasible de ser regenerado por la bioingeniería. Hacen falta patrones estandarizados para poder aplicar protocolos. Pero cada vez más la realidad se presenta eventual, sin ninguna referencia a la que atenerse.
La crisis moderna es una crisis de lo real. Estamos frente a un mundo donde no hay sino semblantes que no llegan a tener verosimilitud. Un mundo donde lo simbólico se consagra a la imagen y donde la función paterna está  en jaque, hasta el punto que hablamos de la feminización del mundo.
¿Qué ocurre en el campo de la psiquiatría? Se produce un cambio brutal en la concepción del sujeto, la creación en los años 70 de un manual de trastornos mentales, periódicamente revisado y corregido dejó atrás las categorías clínicas que la psiquiatría clásica, especialmente alemana y francesa habían puesto de relieve con su exquisita semiología y sus descripciones finas y detalladas. El DSM fue mutando hasta llegar al DSM V, anunciado para el 2012 y postergado. A lo largo de los DSM se produce “el rechazo de la histeria, luego de la melancolía y finalmente la locura”(2). El DSM V plantea una clasificación por categorías para instalar un continuum donde el trastorno de personalidad complica las cosas y por lo tanto está destinado a desaparecer. El problema que tienen que resolver es que necesitan el prototipo, la norma para medir el caso. Y entonces cada caso debe responder a ciertos parámetros, lo que permite la confección de protocolos, el caso tipificado deberá estar clasificado en el manual. El medicamento es el gadget fundamental para sostener este aparato. En su comentario del libro El tiempo de los antidepresivos de D. Healy, Silvia Grases dice que “La industria de especialidades farmacéuticas ha sido una de las primeras en vender un estilo de vida antes que un simple producto” (3). El diagnóstico con su perspectiva única, el juicio de quien lo pronuncia, no tiene lugar en este panorama.
 El psiquiatra en nuestra época queda confundido con el desecho,- pueden leer en Psiquiatría.net un artículo titulado: “¿Psiquiatría: una especialidad para fracasados?”-, cada vez menos se elige al terminar la carrera de Medicina la especialización en psiquiatría. La reciente ley de Salud Mental en nuestro país cuestiona las incumbencias, el psiquiatra está a la par de un asistente social para poder indicar una internación, se coquetea con la idea que los psicólogos puedan recetar. Y se escribe allí que la medicación no puede indicarse como castigo. El Otro social supone un psiquiatra amo, castigador y mal intencionado. Muchos se  consideran relegados en los servicios y deben ocuparse de los pacientes más difíciles, sin el apoyo de la técnica, salvo el DSM, que hace las veces del aparato diagnóstico. La enseñanza oracular de Lacan se ve así confirmada, “nuestro porvenir de mercados comunes encontrará su contrapeso en la expansión cada vez mas dura de los procesos de segregación”. Es el propio psiquiatra el segregado. David Healy, señala que la desinstitucionalización parece haber afectado más a los psiquiatras que a los pacientes.
Cito a Lacan hablándole a los psiquiatras: “el progreso de la civilización universal va a traducirse, no solo por un cierto malestar sino por una práctica de la que verán que va a volverse cada vez más difundida: la segregación” Y agrega: “ustedes podrán tener algo para decir sobre los efectos de la segregación, sobre el verdadero sentido que esto tiene. Porque saber cómo se producen las cosas permite darles una forma diferente, un alcance menos brutal, más consciente a la dicha segregación”. Dice  que esto va a verse en 30 o 50 años, y en ese momento el historiador dirá: “Dios mío, los queridos psiquiatras nos dan un modelo de lo que hubiera podido hacerse en ese momento como cogitación que sirva, pero no lo dieron porque dormían y porque no vieron claramente de qué se trataba en su relación con la locura a partir de un cierto período.”
Vemos anticipado en 40 años el problema en que actualmente se encuentra la función del psiquiatra. Sin los instrumentos cientificistas, como las técnicas que se desprenden de las neurociencias, su papel se encuentra tan difuso como las mismas fronteras que borra el autismo contemporáneo. El universal del diagnóstico como única arma y los “avances” de la psicofarmacología no le dejan escapatoria para poder enfrentar la locura, que hoy se ha vuelto ordinaria.
Entonces,  ¿por qué hoy el psiquiatra se acercaría al psicoanálisis? Los psicoanalistas deberemos  estar atentos a las consecuencias de la universalización y sus efectos sobre el lugar del psiquiatra y como siempre evaluar las demandas una por una para poder responder de la buena manera.
*Sidon, P., ”Los tres cuerpos del psiquiatra. El porvenir es Lacan”, Virtualia 23.
(1)Lacan, J. : Breve discurso a los psiquiatras pronunciado en  el Cercle  Psychiatrique H. Ey, Sainte Anne, el 10 de Noviembre de 1967.
(2) Dewambrechies-La Sagna, C.,”El rechazo de la psicosis”, El Orden simbólico en el siglo XXI,  Grama, 2012, pag 395