La formulación clínica del caso: su valor para la práctica clínica / Clinical case formulation: its value to clinical practice

La formulación clínica del caso (fcc) ha sido objeto de un número creciente de publicaciones científicas. La expresión fcc no es de uso general en nuestro medio, donde en el ámbito docente se utiliza el término «encare clínico¼, con un sentido comparable en algunos aspectos, pero más restringido. Este trabajo se propone revisar las publicaciones actuales sobre el tema con el objetivo de examinar las ventajas e inconvenientes que podría tener un uso más generalizado de esta herramienta clínica. La fcc es especialmente útil cuando el tratamiento del paciente pone en juego una dimensión psicoterapéutica, lo cual exige dar especial importancia a los aspectos psicosociales y a los significados personales del paciente. La formulación del caso explicita la visión del clínico tratante sobre los problemas centrales del paciente, sus hipótesis etiopatogénicas, la estrategia terapéutica y la respuesta del paciente y su evolución. El trabajo propone los lineamientos para un modelo de fcc común a las distintas orientaciones psicoterapéuticas y discute sus características a partir del análisis de la formulación de un caso tomado de la literatura (Johnstone y Dallos, 2014). Se discute la utilidad de la fcc como anexo a la historia clínica y se examina su aplicación en diversos niveles: para el trabajo clínico, para la atención institucional, para la docencia y para la investigación.

YI Suki's Yoksimanpil and the Professional Identity of a Chung'in Medical Official in Eighteenth Century Choson Korea / 의사학

About one hundred years after the publication of Tonguibogam (1613), a physician at the court YI Suki (1664-?) wrote a medical manuscript titled Yoksimanpil (Miscellaneous Jottings on Medical Experiences and Tests, 1734). As indicated in its title, Yoksimanpil was a medical essay composed of 130 medical case histories, drawing on what YI Suki himself had experienced in his medical practices. This paper examines the messages YI Suki in Yoksimanpil tried to address to his fellow Korean doctors, and by doing so illuminates an aspect of the medicine in the late Choson period. The argument goes that YI Suki wrote Yoksimanpil as a vehicle for promulgating his professional identity as a bureaucratic physician who belonged to the network of the chung'in technical officials-a group of government technical functionaries in late Choson Korea. Throughout the late Choson period, the chung'in technical officials had been discriminated, institutionally and socioculturally, against the yangban literati, while their promotion to honored higher positions was blocked. It was in the late 17th and early 18th century that a group of chung'in officials tried to secure their sociocultural places for their professional activity, thus bringing to light their social and professional identity in Choson society. A member of the network of the chung'in technical officials in the early 18th century, YI Suki was in an effort to position himself as a doctor somewhere between the medical tradition and the Confucian literary tradition. In these sociocultural contexts, we can see more clearly what YI Suki tried to speak of in his book and the historical meaning of the medical writing Yoksimanpil. First, the way he practiced medicine was testing and confirming what the received medical textbooks had asserted (Chunghomkobang). This style of practicing medicine could be viewed as a reflection of the comprehensivity trait of bureaucratic court physicians network YI Suki belonged to. Also this type of practice has the implication that YI Suki himself was a well-versed practitioner following the medical textual tradition, which was closely associated with the medical officials network. The emergence of the practice Chunghomkobang could be better understood in the backdrop of over 100 years of maturation process of Tonguibogam in the clinical practices. Second, he formulated the professional identity of physicians only in terms of medical proficiency without recourse to the Confucian literary tradition. In other words, in promoting the social status of medicine, he did not resort to Confucian morality. He instead emphasized his dexterity or resourcefulness in dealing with millions of ever-changing diseases (Imsikwonbyon). Conceivably, this way of characterizing his own medical practice-by way of strongly combining the textual tradition and the experiential tradition while keeping distance with the Confucian literary tradition-reflected the complexity of the ambivalent identity of the technical chung'in officials, especially in regard to Confucianism, between Confucian physicians and hereditary doctors. All in all, YI Suki presented himself as an ideal image of the physician, which arguably reflected the sociocultural and academic context of the network of the chung'in technical officials in early 18th century Choson Korea.

O histórico de caso e a insuficiência da trama / The case history and the insufficiency of the plot

A partir da pergunta sobre a relação entre a transmissão da psicanálise e a estrutura dos históricos de casos, destacam-se duas posições em torno de sua natureza: uma que pretende que eles visem a transmissão transparente dos fatos sucedidos na análise e outra que resgata sua dimensão narrativa enquanto relato, cuja trama brindaria coerência. O trabalho postula que para a psicanálise a trama é sempre falha e assinala os modos freudianos de tornar isso evidente: a ênfase no fragmentário e um modo particular de enunciação. Conclui-se perguntando quais seriam as estratégias à disposição de cada analista para incluir na narração dos casos o que é irredutível a ela.

Starting from the question on the relation between the transmission of psychoanalysis and the structure of case histories two views on the nature of case histories are presented. One maintains that these texts must point to the transparent transmission of the facts that arise during the analysis, and the other emphasizes its narrative dimension as a Report, with a plot which would provide coherence. This paper propounds that for psychoanalysis the plot is always inaccurate, and refers to the Freudian ways of making it evident: the emphasis on the fragmentary and a peculiar way of enunciation. The paper ends with a question about the strategies which every analyst must pursue to include in the narrative of cases what is irreducible to it.