Thursday , August 11 2022

"Doctors have lost control over drugs that have gone to bureaucrats"


By Carlos Lezcano
Especially for Him Seaside

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

– When and how do you travel to the United States?
– I finished medicine, I already knew a lot of English and studied German, because I had the opportunity to specialize in Germany, the Netherlands or the United States.
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 pay was minimal and higher with the scholarships, can not work outside the university.
In the United States, the system was different. You have a job as a resident in a hospital and paid me a good salary that was three or four times higher than what I was paid in Europe.
At that time there was also a sad phenomenon in the US. They were in the middle of the Vietnam War, and many young doctors were sent there, and hospitals in the United States needed more young doctors for their homes in hospitals. This situation helped me a lot. I took the necessary exams to revalue my diploma in the United States, which was an extraordinary effort. It was a three-day exam, where you asked questions about absolutely everything from the subjects of medicine, from the first to the last year. And of course, in addition, everything in English.
During the preparation for the exam, I have already sent a request with all my data to about 60 hospitals in the United States. After we gave the test, we had to wait about three months for the results to arrive by mail. He was there, waiting for the results letter, when on the afternoon the phone rang home. They called me out of a hospital in Philadelphia. "Look, we offer you a residence, we offer you a furnished apartment and we'll pay you $ 900 a month." Then, through a series of coincidences and good luck, I succeeded in continuing my preparation at the hospital of my dreams in Boston, because it is associated with the Harvard Medical School and the best diabetic clinic in the world. It's called the Joslin Clinic, which has some of the medical care and an entire part of diabetes research alone.
– What is there and there is no other place?
– a high level of research and have excellent medical care as well. I have seen 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 hospital, called New England Deaconess. The Joslin Clinic only has ambulatory clinics, has no hospitalization.
– How is it in this system to study and function?
It's relatively simple. 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, much over me. They were all titans of medicine. During the clinical meetings ("breakfast breakfast") that we had every morning, I saw how they manipulated medicine science, diagnostics and treatments with so much knowledge and experience. That made me study and study and study.
– And when was the time to learn?
– In university hospitals in the United States, clinical activity is fully integrated with education. The first day I started at the Boston hospital, I was assigned a patient apartment, two senior residents and two or three medical students to work, control and teach. So I had to run a team of about 5 or 6 people where I treated hospitalized patients with very serious problems and at the same time I had to teach them. That was forever a medical resident. Later, when I was already a resident at the Joslin Clinic, I had to do much more learning, especially in the year I was the boss there. He did much more than learn, he had to organize all of the week's conferences, which were many, organized the interaction of the clinical part with "research titans" who do not see the patients and do not have a more scientific view of the problems. Above the disease, researchers see molecules and mechanisms, trying to advance our knowledge. This has created a lot of very important discussions, almost daily, where we all learned.
For this we had less work of "welfare". I did an outpatient clinic, alone or with younger residents, three afternoons a week, nothing more. For the rest of the time, I had a free letter to dedicate myself to education, the various weekly conferences I had to organize, find interesting cases to discuss, get speakers for each topic, not only in the clinic, but elsewhere in the US … or the world in times.
– Why do you think other residents are better?
– Since almost all Americans have been trained in the best medical schools in the United States, not only in Harvard, we have Columbia, Yale, Hopkins, Stanford and other college graduates with a high level of education and training. Besides, they were very intelligent and dedicated. But it came a day when I started to feel a little better. One weekend I was in duty at the hospital and a diabetic patient was rarely admitted with rare complications that did not seem diabetic, responsible for 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 besides, he was a very good people and a great friend. The beeper sounds for me, I answer by phone, David said to me, "Arturo, admit a patient with very strange problems, would you do me the great favor of coming to see him and help me?" Initially, I thought it would be a joke … but David was so "perfect" he did not joke. More frightened than interested, I went to see the patient. First, David presents the entire clinical history and then examines it together. I immediately noticed a few abnormalities that the patient had, which were not necessarily caused by diabetes, and I remembered something I had studied about him. I said, "It seems to me that this patient has a very rare diabetes due to an excess of iron accumulation in the body." I thought it was a rare hereditary disease called hemochromatosis. It was the coincidence that I read a lot about this disease, because I am interested in the rare and its relation to iron metabolism. I've never seen a case before, but … I remembered that they have a severe arthritis, have a liver strengthening, and a testicle atrophy. The most obvious clinical feature is that their skin darkens as if they were "toast". In the past, they call it "diabetes" because of this. That same night I ordered all the necessary tests, which confirmed the diagnosis, and the next day we presented it to the other residents together with David. To present a case of "equality" with David for me was glory. Since then, my status has changed, not only with the other residents, but within me. I started to feel like "I'm coming," that I was not so inferior to the others.
Has it changed the special relationship you have with your patients?
– It has changed a lot, the medicine has changed a lot. First of all, we lost a great sense of science and academia, medicine has become more of a business. Unfortunately, doctors lost control of the drug that went to bureaucrats, people who only understand business and money. Doctor-only medicine may become more expensive, but drugs in the hands of bureaucrats become very impersonal, where health and pain are far less important than pesos and cents. Doctors became employees of health systems around the world and every day with more documents and bureaucracy, even if they were printed. This means that we have less time to know and understand the patient at the same time as we increase the economic interests of seeing more patients each day to survive. Financial bureaucracy of health has overcome efficacy and has distorted the basic interests of medicine. And I say medicine instead of a doctor because hospitals and clinics are handled in the same way. Cost over efficacy, not taking into account the needs of patients. Physicians are becoming less and less effective throughout the bureaucracy of private and public health systems. It is a struggle between cost control and the opportunity to provide patients with the best and latest science. I have to confess that, at least in part, science is also to blame.
– What does health insurance do in these cases?
– Health insurance forces us to act differently from what our experience tells us and we are forced to navigate between these multiple interferences and blockers. The treatment to be administered is not what we consider the best, but the assurance allows us. Medicine must be a direct relationship between the doctor and the patient, but this inflexible, tasty and insensitive mediator, which is the health system, has been added to it. A fever has been created between the patient and the doctor, starting with bureaucracy for both patients and physicians. The imposition of economic decisions has been created over the scientific ones.
– It's a long time. Sometimes time is urgent.
"Time is money," says the English, "in our case, the time of each consultation is very important, but now we need to use it more for bureaucracy than to talk and try to know the patient." I do not think I can treat a patient without, I know 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 illnesses such as those I treat, diabetes , hypertension, cholesterol, obesity etc. At this point, it is impossible to have enough time for this. Moreover, the universal use of computers, instead of relieving their bureaucracy, has led them to doctors.
-In your specialty, what is endocrinology, what are the main problems at this time?
– With regard to endocrinology, we have two major areas: the first, which is the largest, 70% of our work is diabetes. "A sweet disease, but with bitter complications." Diabetes is an explosively growing problem in the world, which poses great challenges that we have not yet solved. Researchers who discovered insulin in Toronto – Canada – part of Nobel prize money to put two Canadian Diabetes associates into two votive lamps that are always in use and deactivate them only on the day we receive diabetes cure. Day after day, month after month are still on …
Science around diabetes has advanced a lot, especially over the last five or ten years. But the root of the type 2 diabetes or the most common adult diabetes is obesity. Increasing obesity worldwide due to the food industry's effect has considerably increased the prevalence of this form of diabetes due to obesity and continues to increase. I have had the opportunity to go to Asia many times, and in relatively poor countries such as India, China, Pakistan and others, obesity has increased and continues to grow because of the constant food industry temptation that offers very appetizing foods and published at a very low price, step or "delivery". Obesity still does not have effective, safe and permanent treatment despite all television news, publications and the Internet. If we can cure or prevent obesity, we eliminate most of type 2 diabetes. Increasing diabetes in the third world presents a more serious health problem. Inappropriate food is relatively inexpensive, making obesity "available to everyone." On the other hand, treatment of diabetes and its complications (heart, kidney, blindness, amputation) are very expensive and many of these countries lack the means to cope with them. It's inexpensive to become obese and have diabetes, but it's costly to treat them.
The second part of the relatively common endocrinology, 30% of our work, is with the thyroid gland, also common, but much easier to treat. To reduce thyroid function or hypothyroidism, treatment is the simplest and most effective in all medicines: a pill that is given every day, economically and without collateral phenomena.
We diagnose thyroid cancer much earlier and it is very rare that someone dies of thyroid cancer with the treatments we have now. Strong thyroid or hyperthyroidism are also very easy to treat. The other problems of endocrinology, adrenal glands, pituitary glands, testicles, parathyroids, etc. are much less common.
– On the one hand, research, but on the other, there are cultural themes of customs. That's right?
– Yes, research does not heal the problems caused by the habits of human nature. This is the problem that sometimes makes me say that "education will not reduce obesity." We all know what we have to eat, but we do not. Food is a pleasure that surpasses intelligence and will. Undoubtedly, there is a genetic tendency for obesity, but the most important factor is diet, an acquired, not hereditary, "modern life" factor that has increased obesity and type 2 diabetes.
– In India, in China … in India are mostly vegan vegetarians.
– Being vegetarian does not mean they're not obese. I always remembered that the elephants are vegetarian. So people who say "I'll become vegetarian or vegan to lose weight" should remember that it's not necessarily what's going on.
-What was the main reason for the study?
– The central issues have always been obesity and diabetes. But I'm also interested in a congenital testicular change, called XXY or Klinefelter syndrome. I'm still studying a woman's disease that has become more common and the most common cause of infertility, the polycystic ovaries. Increase in calcium in the blood and, as mentioned before, hemochromatosis.
In recent years, I have also dedicated myself to a thing that is closely related to obesity, which is the sense of taste. I am convinced that the sense of taste through its "pleasure and comfort" effects in the brain has much to do with the fact that we eat more than we need. It is not a meal for calorie needs, it is a diet for the pleasant effect that calories produce at the cerebral level and that little by little we understand more. We have prepared a series of lectures to try to explain obesity by increasing what we eat for pleasure, what I call "emotional appetite".
– How does taste and saturation work?
Feelings of taste and satiety are united in two interconnected centers in the middle of the brain, in an area called the hypothalamus. We have gone a long way in recent years to understand how these two centers work through chemicals called neurotransmitters. One of the most important is the "Agouti Factor", originally discovered in the determination of the rodent layer in Latin America, which actually has the name Guaranu, Acuti.
Even the appetite …
– The problem people have is that we have been scheduled to tolerate the lack of food very well. As soon as we do not have enough food and we begin to lose weight, there is a very intense feeling of hunger, which makes us eat and prevents us from losing weight. On the other hand, we do not have protection for overweight, one begins to increase slow weight without becoming aware of it. The most obese do not initially realize that they have become accustomed for a long time. Once obesity is established, it is very difficult to stop it and lose weight.
– And how do you see the obesity operations?
– We have to do it forcefully for very obese people because we do not have effective and safe medical treatments. Our hospital in Boston has been one of the pioneers in carrying out these operations, which are now called "bariatric" and are already being done around the world. When we started, we had a lot of surgical and metabolic problems, but now it can be done with minimal risk in experienced centers that are committed to follow their patients for the rest of their lives. After the initial benefits of these "gastric bypasses" there are metabolic problems to be prevented and / or treated. The main thing is that after about 5 years, many patients start to gain weight. It's an organic and psychological mixture.

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