"Doctors lost control over medicines that were handed over to bureaucrats"

From Carlos Lezcano
Especially for El Litoral

Arturo Rolla came to visit family and friends as he does every year, and at the same time to present his book "Corrientes de recuerdos" with the anecdotes of his youth and adolescence. He will be followed later by another similar book with anecdotes from his life in the United States.

– When and how do you travel to the United States?
– I was finishing medicine, I already knew a lot of English and I studied German because I had the opportunity to go to Germany, the Netherlands or the United States to specialize.
To go to Germany and the Netherlands I had to get a scholarship, and the European scholarships paid me very little. I was already married, my wife was pregnant, the payment was minimal and higher with those scholarships you can not work outside the university.
The system was different in the United States. You got a job as a resident in a hospital and they paid me a good salary that was three or four times more than what I paid in Europe.
At that time there was also a sad phenomenon in the US. They were in the middle of the war in Vietnam and many young doctors were sent there, and hospitals in the United States needed more young doctors for homes in hospitals. That situation helped me a lot. I took the necessary exams to confirm my diploma in the United States again, which was a huge effort. It was an exam that lasted three days, asking you questions about absolutely everything from medicine, from the first to the last year. And of course everything in English.
While I was getting ready for the exam, I had already sent an application with all my data to about 60 hospitals in the United States. After giving the test we had to wait about three months before the results arrived by mail. He was there, waiting for the letter with the results, when one afternoon the telephone sounded at home. They called me from a hospital in Philadelphia. "Look, we offer you a home, we give you a furnished apartment and we're going to pay you $ 900 a month." Then, through a series of coincidences and good luck, I managed to continue my training in the hospital of my dreams in Boston because it is associated with the Harvard Medical School and the best diabetes clinic in the world. It is called the Joslin Clinic, which has a part of the medical care and a whole part of the research only for diabetes.
– What is there and that there is no other place?
– A high level of research and they have the medical care that is also excellent. I saw patients from all over the United States and around the world with all the problems and different types of diabetes. I started working in the part of the hospital called the New England Deaconess. The Joslin clinic only has outpatient clinics, there is no hospitalization.
– How is it done in that system to study and work?
– It is relatively easy. You work a lot and you study a lot. When I arrived in Boston I immediately realized – it was very easy! – that the level of the other inhabitants of my year was very high, far above mine. They were all "titans of medicine". In the clinical meetings ("work breakfasts") that we had every morning, I saw how they treated the science of medicine, the diagnoses and treatments with so much knowledge and experience. That forced me to study and study and study.
– And when did the time come to teach?
– In the university hospitals of the United States, clinical work is fully integrated with education. The first day I started in the Boston hospital, I received a patient apartment, two first-year residents and two or three medical students to work, monitor and teach. So I had to manage a team of about 5 or 6 people, where we treated hospitalized patients with very serious problems and at the same time I had to teach them. That was a medical resident throughout my time. Later, when I was already an endocrinology resident in Joslin's clinic, I had to teach a lot more, especially in the year that I was chief commissioner there. He did much more than teaching, he had to organize all the conferences of the week, which were many, he organized the interaction of the clinical part with the "research title men" who do not see patients and have a more scientific view of the problems. Above the disease, researchers see molecules and mechanisms in an effort to increase our knowledge. That has resulted in many discussions, very important, almost daily, where we have all learned.
For this I had less "welfare work". I did an outpatient clinic, alone or with younger residents, three afternoons a week, nothing more. The rest of the time I had a free letter to dedicate myself to education, several weekly conferences I had to organize, find interesting things to discuss, get speakers for each topic, not only in the clinic but also in other parts of the world. the US … or the world at times.
– Why do you think the other residents were better?
-Because almost all Americans were trained in the best medical schools in the United States, not just in Harvard, we had resident graduates from Columbia, Yale, Hopkins, Stanford and other universities with high levels and preparation. Apart from that, they were very intelligent and dedicated. But there came a day when I started to feel a bit better. I had a weekend in the hospital and a patient with very rare diabetes was admitted, with rare complications that did not seem diabetic, who were in charge of one of the best residents, David. He was one of my most envious idols, not only because he was very intelligent and knew a lot, but he was also a very good person and a great friend. The beeper sounds to me, I answer by phone, it was David who said to me: "Arturo, I admit a patient with very strange problems, would you like to prove me the big favor to visit him and help me?" At first I thought it would even be a joke … but David was so – & # 39; perfect & # 39; that he did not joke. More scared than interested, I went to the patient. First, David presents the entire clinical history and then we look at it together. I immediately noticed several abnormalities that the patient had, which were not necessarily caused by diabetes, and I remembered something that I had studied about it. I said, "It seems to me that this patient has a very rare diabetes due to excess iron buildup in the body." I thought it was a rare hereditary disease called hemochromatosis. It was a coincidence that I had read a lot about this disease because I was interested in the rarity and its relation to the metabolism of iron. I had never seen a case of that before, but … I remembered that they have a severe form of arthritis, they have hardening of the liver and atrophy of the testes. The most obvious clinical feature is that their skin becomes darker, as if they were "roasted". In the past they called it "tanned diabetes". That same evening we ordered all the necessary analyzes, what the diagnosis confirmed and the next day we presented it together with David to the rest of the residents. Presenting a case "on the same line" with David for me was the glory. From that moment my status changed, not only with the other residents but also with me. I began to feel that I "came" that I was not so inferior to the others.
– Has the specific relationship you have with your patients changed?
-Has changed a lot, the medicine has changed a lot. Firstly, we have lost a great sense of science and the academic world, medicine has become more of a matter. Unfortunately, doctors have lost control of the drug that has gone into bureaucrats, people who only understand business and money. Medications that are only managed by doctors can eventually become more expensive, but medicines in the hands of bureaucrats become very impersonal, with health and pain being far less important than pesos and cents. We doctors have become employees of health systems around the world, and every day with more paperwork and bureaucracy, even if they are typed. This means that we have less time to know and understand the patient, while at the same time increasing the economic interests to see more and more patients every day to survive. The financial bureaucracy of health has surpassed effectiveness and has distorted the basic interests of medicine. And I say medicine instead of doctors, because hospitals and clinics are treated in the same way. Cost effectiveness, without taking into account the needs of patients. We doctors are becoming less efficient in the bureaucracy of both private and public health systems. It is a struggle between cost control and the ability to offer patients the best and latest science. I must confess that, at least in part, science is also the fault.
– What does a health insurance do in these cases?
-The health insurance forces us to act in different ways to what our experience tells us and we are forced to navigate between these multiple and blocking interferences. The treatment to be given is not the one we consider the best, but the only insurance that allows us. Medicine must be a direct relationship between doctor and patient, but this inflexible, economical and insensitive intermediary, who is the health system, has been added. A wedge has been created between the patient and the doctor, starting with the growing bureaucracy for both patients and doctors. The imposition of economic decisions is based on scientific decisions.
– It means a lot of time. Sometimes time is urgent.
"Time is money, the English say, in our case the time of every consultation is very important, but now we have to use it more for the compulsory bureaucracy than to talk and try to get to know the patient." I do not think I can get a patient to treat without knowing him, without understanding his personality, his way of being, his life, his family, his environment, medicine is not and must not be impersonal, and in patients with chronic diseases such as I treat, diabetes, hypertension , cholesterol, obesity, etc. At the moment it is impossible for us to have enough time for it, and the universal use of computers instead of reducing bureaucracy has also increased this for physicians.
– What are the most important problems in your specialty, endocrinology, right now?
– Within what is endocrinology we have two main areas: the first, which is the largest, 70% of our work is diabetes. "A sweet disease but with bitter complications". Diabetes is a problem that is growing explosively worldwide, which presents us with great challenges that we have not yet solved. The researchers who discovered insulin in Toronto – Canada left part of the money they won with the Nobel Prize to place two votive lamps in the Canadian Diabetes Association that are always on and off on the day we cure of diabetes. Day after day, month after month they are still on …
The science of diabetes has made a lot of progress, especially in the last five or ten years. But the cause of the problem of type 2 diabetes or adult, the most common, is obesity. The increase in obesity worldwide as a result of the effect of the food industry has greatly increased the prevalence of this form of diabetes as a result of obesity and continues to rise. Many times I have had the opportunity to go to Asia, and in heavier countries such as India, China, Pakistan and others, obesity has increased and continues to increase due to the constant temptation of the food industry, which offers very tasty and well-known food, for a very low price, step or with "delivery". Obesity still has no effective, safe and permanent treatment, despite all the news on television, publications and the internet. If we could cure or prevent obesity, we would eliminate the majority of type 2 diabetes. The increase in diabetes in the third world is an even more serious health problem. Junk food is relatively cheap, making obesity & # 39; within everyone's reach & # 39; is. On the other hand, the treatment of diabetes and its complications (heart, kidneys, blindness, amputations) are very expensive and many of these countries do not have the economic means to deal with them. It is cheap to get obese and get diabetes, but it is expensive to treat them.
The second part of relatively common endocrinology, 30 percent of our work, is with the thyroid gland, also common, but much easier to treat. For the reduction of thyroid function or hypothyroidism, treatment is the simplest and most effective in all medicines: a pill that is taken every day, economically and without any additional symptoms.
We diagnose thyroid cancer much earlier and it is rare that someone dies from thyroid cancer with the treatments we now have. Too active thyroid gland or hyperthyroidism are also very easy to treat. The other problems of endocrinology, adrenal glands, pituitary gland, testicles, parathyroid glands, etc., are much less common.
– On the one hand, research, but on the other hand there are the cultural themes of habits. Is that right?
-Yes and research do not cure the problems caused by the habits of human nature. This is the problem that causes me to say sometimes: "information will not reduce obesity". We all know what to eat, but we do not. Eating is a pleasure that surpasses intelligence and will. Undoubtedly there is a genetic tendency to obesity, but the most important factor is the increase of the diet, an acquired factor, not hereditary, "of modern life" with increased obesity and type 2 diabetes.
-In India, in China … in India it is mainly vegans, vegetarians.
– The fact that you are a vegetarian does not mean that they are not obese. I always remind you that elephants are vegetarians. So it is that people who say "I am vegetarian or vegan to lose weight" must remember that it is not necessarily what happens.
– What was the main reason for study?
– In short, the main problems were always obesity and diabetes. But I am also interested in a congenital change of the testes, called XXY or Klinefelter syndrome. I am still studying a disease of women that is much more common and the most common cause of infertility, the polycystic ovaries. Increased calcium in the blood and, as I said before, hemochromatosis.
In recent years I have also devoted myself to something that is closely related to obesity, which is the taste. I am convinced that the sense of taste due to the effects of "pleasure and comfort" at the level of the brain has much to do with the fact that we eat more than we need. It is not a meal for calories, it is a food for the pleasant effect that calories produce at the cerebral level and that we gradually understand more. I have prepared a series of lectures to try to explain obesity by an increase in what one eats for pleasure, what I & # 39; the emotional appetite & # 39; name it.
– How does taste and satiety work?
-The feelings of taste and satiety are united in two centers that are connected in the middle of the brain, in an area called the hypothalamus. We have come a long way in recent years to understand how these two centers work with chemical products called neurotransmitters. One of the most important is the "Agouti Factor", originally discovered in the determination of the fur of a Latin American rodent that actually bears the name Guarani, Acutí.
Appetite and satiety …
– The problem that people have is that we are programmed to tolerate the lack of food well. Immediately if we do not have enough food and we start to lose weight, a very intense feeling of hunger appears, which leads us to eat and prevents us from losing weight. On the other hand, we have no protection for overweight, one starts to arrive slowly, without realizing it. Most obese people do not initially realize that they have become obese for a long time. Once obesity is established, it is very difficult to stop and lose weight.
– And how do you see the operations related to obesity?
-We have to force them with very obese people because we do not have effective and safe medical treatments. Our hospital in Boston was one of the pioneers in carrying out these operations that now & # 39; bariatric & # 39; and are already being implemented all over the world. When we started, we had many surgical and metabolic problems, but now it can be done with minimal risk in experienced centers that commit to monitoring patients for the rest of their lives. After the first benefits of these "gastric bypasses" appear metabolic problems that need to be prevented and / or treated. The most important is that after about 5 years many of the patients start to weigh again. It is an organic and psychological mix.

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