Medicina 58 010443
Medicina 58 010443
Medicina 58 010443
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Abstract: The increasingly swift changes in the field of medicine require a reassessment of the skills
necessary for the training of technically qualified doctors. Today’s physicians also need to be capable
of managing the complex issue of personal relationships with patients. Recent pedagogical debates
have focused on so-called “soft skills”, whose acquisition is presented in literature as a quite recent
addition to medical studies. Moreover, the historical investigation of deontological texts dating from
the mid-nineteenth century back to the Hippocratic Oath shows that medicine has always discussed
the need to integrate technical expertise in medicine with specific personal and relationship-based
skills. Debates have often circled around whether these “soft skills” could actually be taught or
how they could be successfully transmitted to training physicians. The belief that defining medicine
is more complex than defining other similar sciences and that the instruments to be used in the
relationship with patients cannot be limited to those provided by technical aspects shows a new
awareness. Today, this view is often stated as an innovative realization on the part of doctors with
regard to the complexity of training and action in a delicate area in which they are entrusted with the
Citation: Iorio, S.; Cilione, M.;
management of the balance of the system that is the human body.
Martini, M.; Tofani, M.; Gazzaniga, V.
Soft Skills Are Hard Skills—A
Keywords: soft skills; deontological tradition; history of patient–physician relationship
Historical Perspective. Medicina 2022,
58, 1044. https://doi.org/10.3390/
medicina58081044
abstract categories. This would lead us to neglect all those “non-technical” and specific
aspects of each individual clinical situation that instead allow for the true understanding of
the disease as a continuous process and change within the patient.
Try not to get used to thinking abstractly about the disease as the pathology describes
it . . . The more you know, the more you can [do]. But do not even dream to imagine
that knowledge is enough. You have to get used to considering the chapter dedicated to a
certain disease by pathologists neither more nor less than a necessary expedient to better
understand, but not as a description of a defined and always equal entity to itself . . . as
there are not two equal things, so there are no equal patients [ . . . ] Thereby, even after
you have made the diagnosis of typhoid fever or any other illness, you have to make the
true special [specific] diagnosis in your patient, day by day. [2]
In his renowned study, “The Birth of the Clinic”, Michel Foucault [3] critically rec-
ognizes how the nucleus of medicine is based on a logos of empirical “visibility” of the
body and disease. Scientific medicine bases its view on the empiricist paradigm that allows
us to look at the body as a thing in a world of things. Clinical method is based on visual
examination. Signs and symptoms are related to the repetition of the frequency of illness.
Therefore, decrypted from the individual meaning, these signs and symptoms become
meaningful. Consequently, pathology assumes a pre-defined meaning.
It is the description [ . . . ] that authorizes the transformation from the symptom into
sign, the passage from the sick person to the disease, access from the individual to the
conceptual. [ . . . ] Describing [this] means following the order of its manifestations, but
it also means following the intelligible sequence of their genesis. It means seeing and
knowing at the same time, because, by saying what one sees, one spontaneously integrates
it into knowledge. This also means learning how to see, because this means giving the key
to a language that masters the visible. [3]
Along these lines, disease is bound to the perception of a mechanistic visibility. There-
fore, it is entirely disconnected from the world of invisibility that builds disease and comes
together to create it. An entirely empiricist view ignores the fact that human beings are
not just bodies but symbolic and social animals, whose existence is understandable in its
multiform manifestations. Disease is obviously part of this. We can reach this multifaceted
understanding only if we consider the social and cultural determinants that contribute to
shaping all individuals of our species in extremely different ways.
Furthermore, leading contemporary definitions, such as that of G. Canguilhem in
1988 [4], underline how the nature of medicine oscillates between the clinical world, aimed
at taking care of the individual or a part of the population, and the need to increase our
level of scientific understanding by making use of basic knowledge and methodologies
addressed at the mere explanation of general pathological and clinical aspects.
A solution to this ontological dilemma appears to be at least partially offered by
medical anthropology. Furthermore, this field of study offers a possible categorization of
medicine as a form of human science and specialized culture. Based on behaviour that
is taught and communicated, medicine has all the characteristics that define subcultures.
Medicine has a peculiar symbolic system of verbal and non-verbal communication, direct
and indirect self-imposed limits, as well as shared ideal models that create behavioural
codes. Moreover, medicine has evolved over time in an adaptive way in order to best apply
this expertise to the needs of a certain context. Consequently, it is integrated within the
cultural context of reference of which it exploits and influences different aspects of life,
changing due to innovation and direct and indirect transmission. Finally, medicine selec-
tively spreads and divulges intuitions and discoveries through assimilation, acculturation
and revolutions. Each of these steps is so closely interconnected with what happens in
specific societies that it is difficult, if not impossible, to understand the profound changes
of medical thought outside the cultural contexts in which it is generated.
Medicina 2022, 58, 1044 3 of 8
18th century and the middle of the following century. Conceived in order to enhance the
figure of the physician in an age in which other health workers were laboriously attempting
to climb the academic ladder (e.g., the first constitutions of obstetric and nursing groups),
the Galatei manuals represent above all a tool to spur the doctor to endow themselves with
the self-awareness necessary for the social affirmation and the gain of public confidence.
The texts of the Galatei repeatedly state that the choice of the doctor should be made on the
basis of good moral and personal skills or knowledge and expertise that he possesses and
that only the recourse to the dualism of science and humanity can guarantee the acquisition
of the trust and confidence necessary for the establishment of a correct doctor–patient
relationship. The prologue of the Galateo for G. Pasta, published in Rome in 1817, also
highlights laws known to the medical community. These laws were learned through science,
but they are also “dear” to patients by virtue of human and behavioural qualities that
form the basis of a code of civilization, which can also be seen as medical “etiquette”.
Science without etiquette (where the word indicates the highest and morally connoted
deontological world) makes us glorious but only for half of it [13]. Moreover, etiquette
requires a moral character on which to be grafted, a personal nature that is “prosperous,
grave, eloquent, tireless, docile, civil”, which makes the doctor capable of acting prudently,
relating with colleagues with cordiality and interest, and in the relationship with the patient,
turning into a friend who is also capable of encouraging and comforting. The “decorum”
proposed by the Galatei texts is not confined to appearance, which must also be impeccable.
There is a substance, a fidelity to the generous and human aspect of the doctor’s soul,
which must be nourished by non-technical instruments, but which are equally fundamental.
Among these, the knowledge of languages, poetry as a tool for setting and controlling the
quality of language, the possession of logical tools that allow us to “observe a great deal,
but rightly observe”, the knowledge of the world, as well as character traits that condition
the patient’s response to conditions of illness, paired with tolerance to diversity and the
ability to apply correct behaviour to different social conditions directly recall a modern
definition of soft skills.
Reference to the need for a complex and thorough medical education is actually a quite
classic theme. It constitutes the pivot of a well-represented pedagogical tradition, in modern
times, from the famous text Dissertatio de recta medicorum studiorum ratione instituenda,
work of the pontifical archiater Giovanni Maria Lancisi, printed in Rome in 1715 [14].
Lancisi’s work is a tried-and-true programme for the training of doctors and surgeons
who work inside S. Spirito, the Roman hospital at the centre of an innovative cultural
project, commissioned by Pope Clement XI and entrusted precisely to the realization of
his archiater. The project foresaw to the establishment of a hospital library, which would
gather the most significant and most recent medical, scientific and philosophical texts,
in order to make them available to those who worked inside the hospital and needed a
“continuing education”. This led to the establishment of an academy, the centre of the
hospital’s “experimental” life and a forum for debate and scientific meeting. Moreover,
the hospital drafted a complete educational project for the doctor in training, expressed in
the De recta, which was based on the extraordinary possibility offered by the hospital to
create a channel of communication among different professionals, allowing them to meet
many patients simultaneously and to consult a vast collection of books. Lancisi firmly
believed that the doctor, in addition to being endowed with all the most innovative cultural
instruments of the time (the knowledge of mathematics, mechanics, chemistry, etc.), must
also be trained in the acquisition and exercise of specific relational skills. They must know
how to speak, not because eloquence is able to cure but because it is an indispensable tool
to convince the patient and engage their trust, in the same way as the dignity of manners
and the authority of behaviour are. Furthermore, they must know the uses and customs of
the world, nourish charity as the main instrument of approach to the disease—a precursor
that religiously connoted our concept of empathy—in order to exercise with prudence and
reason what should be done. The concept was that if something is completed quickly, it
can help avoid other problems. A physician must also apply a clear-cut logical method,
Medicina 2022, 58, 1044 6 of 8
which allows them to illuminate the “dark ravines” of the reflection on the nature of the
body. The construction of this method requires some tools, not all provided by technical
studies. It feeds on knowledge of the world acquired through travelling, experience and
mental journeys in books and illustrations (the paper world, for those who—like Lancisi—
founded a library, is equivalent to the geographical world). Clearly, the physician needs
doctrine, but they should also have a good and generous nature, willing to be shaped, from
childhood, by education, working with dedication and “continuous time”. For Lancisi,
the possession and cultivation of apparently secondary abilities is not to be understood
as a decorative tool. These skills are an indispensable qualification, due to the fact that
medicine, which “scientiam sibi vero comparare volet” (which aspires to become a science,
which aims to be compared to a science) can lay the groundwork to legitimize the aspiration
to implement its epistemological status. That said, some small mistakes must be avoided.
Certain cultural trends of the time (polymathia, wanting to know a little about everything,
for example) should be avoided, just as the excessive use of artistic and cultural activities
(poetry, theatre, music, antiques). This trend would end up becoming a distraction for
training doctors, who must not lose their clarity, perhaps obscuring good reasoning with
an excess of rough and confusing notions. However, none of the stimuli that come to us
from these examples of early modern and late modern medical literature is entirely new to
medicine. Some of these features are defining aspects in older works, ascribable to Greek
and Latin medical literature, which paved the road to Western medicine starting in the
late ancient period. Galen’s beliefs on the need for the doctor to also be a philosopher,
holding a solid knowledge of logic, physics and ethics, led to the development of an
ontological foundation for medicine in the Imperial Age, anchored to the dualism of science
and philosophy. In a mutual process, medicine and philosophy lend to each other their
own methodological tools, so that without scientific basis even philosophy is reduced
to a mere rhetorical exercise and a series of unmotivated controversies [15]. Pedagogy,
to which Galen devotes a large part of his writings, is depicted in the same treatise as a
maieutic process in which the master guides the pupil. The student’s views are rendered
acute by experience and acquired knowledge, towards the contemplation of intelligible
objects. In medicine, this translates into the acquisition of the experience data necessary
to formulate the prognosis, through their selection and re-composition within a coherent
logical framework that explains the onset of the disease [16]. The student’s conduct towards
the acquisition of skills is not only mediated by the teacher’s more developed insight but
also by a series of conditions that fall entirely within our definition of soft skills: an early and
constant exercise in fundamental skills; possessing a “penetrating nature” and a naturally
curious disposition towards the leading intellectuals of the time, and the constancy of
applying oneself to continuous study; absolute dedication to work; the intellectual tension
that leads to the search for truth through the possession of a method that allows to discern
what is true from what is false; and lastly, daily exercise in this method, so as to master it
and know how to apply it with satisfactory results [17].
The Galenic attitude towards the patient, often quite stern and connected to an absolute
and rigid paternalism, does not indulge in defining the doctor in terms of human qualities.
However, this attitude is compensated, in ancient literature, by an entire series of concepts
summarized in the famous figure of the medicus amicus. Medical sources (Celsus and
Scribonius Largus, 1st century CE) and literary sources (Seneca and Cicero) repeatedly
describe the human qualities necessary to be a good doctor. Celsus expressly states that,
with the same skills, it is preferable to have a doctor who presents himself as a friend rather
than as a detached and extraneous professional. Furthermore, he adds that mercy, which
is the attitude of the soul that opens up to the patient’s understanding, is a tool that can
improve the performances of medicine [18]. Scribonius Largus, for his part, emphasizes that
a fundamental cornerstone of medicine is the foundation of the will with which medicine
moves forward [19]. Consequently, this will cannot be excluded. At times, the tradition
goes a step further. Quaestiones medicae, attributed to Soranus, puts forward an opinion
ascribed to the Alexandrian doctor Erasistratus, which affirms that, despite the fact that
Medicina 2022, 58, 1044 7 of 8
the combination of professional expertise (in arte perfectus) and human virtues ](moribus
optimus) certainly represents the ideal condition when imagining the perfect doctor, in
the absence of one of them, “it is better to be a good man who lacks in doctrine (absque
doctrina) rather than being a perfect technician with a bad personality, good virtue” [20].
These technical voices are echoed in the passionate words of famous patients such
as Seneca and Cicero. Their testimony gives life to those “using” medicine. These voices
are often evanescent, mute and difficult to reconstruct in all Western medical literature.
For them, those who lose a doctor’s human capacities are left orphans of a skill that
money cannot buy and which cannot be replaced even through the use of a more perfected
technique. What the patient asks is time dedicated to him by the doctor, choices of his
case compared to the many others who request his presence, promptness of intervention
and solicitude in assistance, as well as the ability to bear the demands of those who suffer,
who can often be bothersome. All this constitutes the real treasure that medical art can
offer—a human skill that makes the professional irreplaceable. The perfect doctor is one
who knows that the occurrence in the same body of the patient and his or her illness do not
constitute an identity as such [21].
4. Conclusions
The need for the patient to have a physician who has studied but at the same time is
highly qualified in human relationships boomerangs back in literature and testimony from
contexts that are sometimes unexpected, such as social and administrative situations. For
example, Greek epigraphic tradition continually attests that the criterion of choice of the
public doctor suitable to take care of the city must be defined based on the evaluation of
technical excellence as well as an appropriate moral attitude. A decree of the sanctuary
of Asclepius in Athens (dating between 46 and 125 CE)—or the numerous decrees that
were dedicated throughout the territory of Greece to doctors known to us only for the
brief mention of their name—highlight the medical episteme to the ethos, that is the set of
lifestyles, customs and moral attitudes that make professionals appreciated candidates for
the management of public health.
The relationship between professional skills and an individual’s personality traits
has been clearly attested since the Hellenistic tradition. Moreover, on a consistent ba-
sis, this relationship underlines the main features of the Hippocratic ethos: the love of
mankind, the foundation of medical art, constitutes one of the main tools thanks to which
the sick regain health. The theme emerges with a certain clarity in the second corpus-
culum of the Hippocratic treatises dedicated to medical ethics: Medico, Precetti e Decoro
(III century BCE - II century CE) [22]. The aspect that unites these writings is the identifica-
tion of the good doctor in a balanced pairing of philanthropy and authority. However, they
also offer practical indications on the appearance and demeanour that doctors are called
upon to carry when they are in front of the patient. This is important not only to avoid
discrediting themselves and their profession but also in order to instil a feeling of trust in
the patient [23]. Moreover, returning to the text of the oath ascribed to Hippocrates, the
combination “life/art” already appears clearly defined in the statement “I will preserve my
life and my art”. The problem of the interpretation of the Greek term “bios”, so connoted in
the text of the oath, can be solved only if, with von Staden, we agree to translate it as the way
of life, the styles and the totality of the actions that shape a human being as such—a doctor
as a doctor, a good doctor as a good doctor. Therefore, we are discussing not only science but
also the set of personality trains and acquired attitudes that today fall within the domain of
soft skills. In conclusion, due also to the therapeutic weakness of medicine, in the historical
tradition, these “human” traits were never described as some sort of accessory [24]; rather,
they are fundamental elements in creating the role of the suitable professional. Perhaps
our thoughts could also wander to “Homo bonus”, created by the hands of an anonymous
patient somewhere around the III century BCE. This graffiti is a sort of thank you note
written on the wall of the visiting cubiculum of the surgeon’s domus in Rimini, Italy. This
Medicina 2022, 58, 1044 8 of 8
is a representation of that luminous figure that passes through the centuries in order to
help the “sufferers” who invoke his help to win their battle against illness.
Author Contributions: Writing—original draft preparation, S.I., M.C., M.M., M.T. and V.G.; writing—
review and editing, S.I., M.C., M.M., M.T. and V.G. All authors have read and agreed to the published
version of the manuscript.
Funding: This research received no external funding.
Conflicts of Interest: The authors declare no conflict of interest.
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