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Venezuela Chapter Governor's Newsletter
July 2002

Israel Montes de Oca MD, FACP-ASIM
Governor Venezuela Chapter

Editorial: ACP-ASIM Essential Values

Israel Montes de Oca, MD, FACP, Governor, Venezuela Chapter

Any medical organization, which intends to improve the population health conditions, must have various orientations to achieve objectives, which tend to solve patient's medical problems. This is the reason why the ACP-ASIM Venezuela's Chapter, following the College's obligation, is responsible to inform its members about the essential values on which our scientific association must act and develop.

This Bulletin will constitute an open tribune to receive our chapter member's opinions. Chapter members will be able to forward their criteria by means of short articles on different topics related to Internal Medicine doctrine and its executor, the internist. Among those topics are all theoretical and practical considerations which have to do with our attitude toward the patient, as we have mentioned elsewhere.

One of the major virtues of Internal Medicine specialty is the integral view and understanding of the patient. This is the essential value that the ill person expects from the physician. The internist, with his/her holistic attitude can facilitate health recovery, as he/she has been vigilant and self-critical of his/her action as repository of patient's confidence.

Authentic internist leadership resides not only on being well trained and informed on contemporaneous medicine but on his/her service capacity and understanding about the suffering of the ill in its whole humanistic spectrum.

Providing education, orientation and advice to the patients solidifies and conjugates the scientific knowledge an internist may have. The own patients and the colleagues of other specialties recognize this.

Science as a training; inspiration and intuition as a will; self-criticism as a self-training, and receptivity as a medical behavior, all constitute Internist essential values and places Internist as a leader in the service of the patient.

We must remember the saying of an anonymous author thought: "If you are good to live, live to serve"

Article on Doctrine: "Internist as a Preventive Agent"

Rolando Salvetti, MD, ACP-ASIM Member

The internist is the integrative physician par excellence of both all human being complexity and the relation every person has with his/her natural, familiar, social and cultural environment, and which influences on a determinant way his/her health. This characteristic as well as the internist fundamental role at all sanitary care levels, makes that within internist actions are disease prevention in healthy subjects and the avoidance of complications in patients who are already ill. Thus, internist embraces all prevention levels (primary, secondary and tertiary). So, we go way beyond the image some have about an internist, that of the physician that takes care of extremely complex patients, making diagnosis of rare diseases which they usually can not cure (surgeons say they are the only doctors that really cure).

Internist preventive action goes from the individual patient up to the community, including the family group. Currently, many infectious diseases in adulthood are vaccine preventable, and chronic diseases may also be prevented and modified by medical action. Internal Medicine Specialists must project their action towards community; labor which is promoted and stimulated by the Venezuelan Society for Internal Medicine and ACP-ASIM, and facilitated by telecommunication advance in a global world, each time smaller for mankind.

We are then in the presence of a new paradigm, where the Internist must be a physician who comes out of the isolation that represents the office and ward, to practice within hospitals and national health clinics by means of the community education for health, taking advantage of the physician natural teaching vocation. Unfortunately, authorities responsible for health care politics in our country do not allow enough room for Internists (if any) within the development and execution of preventive sanitary actions, wasting a highly valuable resource. Therefore, our job must be guided by Scientific Societies that we belong to, adding that to the individual actions that some of us can execute. There are colleges that have access to different media, writing in newspapers and magazines, or conducting or participating in radio and television programs. Some other Internists contribute with their knowledge on Internet, where there are web pages devoted to education for health in a serious and responsible manner.

However, there is one aspect we must not forget as this is to be coherent with what we think, say and do. We can hardly advise a patient to stop smoking if we do not do it ourselves. The same happens when we recommend someone to exercise and we rank first in the sedentary life world championship. In order to gain the respect from other people we must be the model that the others get encouraged to follow. Internists are leaders by nature, for which our attitude must be active and aimed to improve the quality of life of our population. This way we contribute to the socioeconomic development of our nation, regardless of the perturbation factors that there may exist.

College News

  1. ACP-ASIM Annual Session 2002. Annual Session 2002 took place on April 11-14 at the headquarters in Philadelphia, with great success. At the session, new fields on continuing education were shown. At the pre-session courses an extensive program was covered on all administrative aspects due by September 11, 2001. The College was able to show its whole organization as an Institution at the stand located within the Commercial Exhibition Hall.

  2. ACP-ASIM Annual Session 2003. Next Annual Session of the College will be held in San Diego (California) on April 3-5, 2003. We invite all Venezuela Chapter Members to attend this event and to take advantage of visiting the beautiful city of San Diego.

  3. ACP-ASIM Name Change. The possible change of College name to one that conveys more clearly the College essence (an organization that gathers Internal Medicine Specialists) was one of the issues set forth at the Philadelphia Annual Session. The possible new name - yet to be approved - would be "American College of Physicians" with the addition of "Internal Medicine Doctors for Adults". We will shortly inform you about the final decision.

  4. Alvan R. Feinstein Memoral Award. The College has established a new College Award, The Alvan R. Feinstein Memoral Award, to be granted to physicians who have contributed to the development of scientific patient care, applying what Dr. Feinstein defined as Clinical Epidemiology and Clinimetry. The first award will be granted in year 2003 at the Annual Session and nomination dead line will be July 1st, 2002. For further information, contact Jean Elliott by e-mail: jelliot@acponline.org.

  5. ACP-ASIM Advantage. A new College Bulletin "ACP-ASIM Advantage" will be published first Wednesday of each month, which will deal with the most recent benefits for ACP-ASIM members and activities to help the Internist with his/her career.

  6. New College Publications. Four new ACP-ASIM publications are on Common Clinical Problems as they are: "Telephone Medicine: A Guide for the Practicing Physician", "Expert Guide to Infectious Diseases", "Asthma", "Practical Gynecology: A Guide for the Primary Care Physician". They can be acquired through the Product & Program Catalog.

  7. PIER. We remind and recommend our Members of the new educational resource PIER (Physician Information and Educational Resource), which allows an access to knowledge in the daily duty of medical decisions. This program is available for Members, free of charge, up to June 2003.

  8. Public Policy. Access to relevant documents of ACP-ASIM public politics are available for Members through the new Public Policy Virtual Library on the College Web.

  9. ACP-ASIM Resoulutions. Many resolutions were discussed and approved during the Annual Session at Philadelphia. The following would be of interest for the Venezuela Chapter Members: Compensation for medical services paid as a bonus by the Insurance Companies was considered to be anti-ethical. Reduction of the fees for the Latin-American Associated Members was not approved. Members were encouraged notify the College of their email addresses to help improve communication.

  10. Pharmaceutical Industry. Important aspects on Doctors and the Pharmaceutical Industry were analyzed during the Annual Session at Philadelphia. Dr. Jay A. Jacobson's speech was directed to inform on this interrelation. Articles on this topic are featured in Ann Int Med 2002;136:396-402 and 403-406 and are recommended.

  11. Issues Brief. The College offers a new monthly publication, which provides a summary of the College public politics role. Those interested can be added to the e-mail list. To receive the"Issues Brief" contact Troy Burnnett at tburnnett@acponline.org

Article on Ethics (III): "Medical Error"

Alvaro Requena, MD, ACP-ASIM Member

Certain practices adopted by physicians may be considered as contrary to medical moral. The medical error is more a topic of conversation than a deontological or legal concept.

Medical Deontology Code mentions specifically the "excusable error" and obviously accepts the possible "made errors" differentiating them from negligence and professional incompetence. Medical Deontology Code points out than "Faults against the medical moral committed due to ignorance, negligence, unskillfulness or dishonesty, duly confirmed, will be sanctioned by the Disciplinary Tribunal of Medical Colleges and Venezuelan Medical Federation....".

The Law for the Practice of Medicine is much more precise on the denominations for the potential sanction that "result from the action, omission, unskillfulness, imprudence or negligence during the professional practice". But the Law for the Practice of Medicine says that only "negligence, unskillfulness and imprudence will be investigated by the Medical College Disciplinary Tribunals".

Both above mentioned Codes recognize negligence, imprudence, and unskillfulness; they both describe "action" and "omission" in the perpetration or generation of deeds which warrant moral and/or legal (also penal) sanction and also accept "ignorance" and "dishonesty" as circumstances which condition of physician's responsibility. But only the Medical Deontology Code accepts "error" as an "excusable mistake" and differentiates it from negligence and professional incompetence. Is it possible to talk about "honest error"?

Before getting to the point, it is important to establish a semantic precision. Following what Dr. Augusto Leon C. says, we will use the term "mal praxis" to "designate any form of inadequate practice in any profession".

Another key term already mentioned is "negligence", which "means neglect, omission, lack of application...". This term "implies more than an imprudent or careless conduct ...." and demands that the physician should "not only have the required skill but also uses it in the right manner". It is obvious that any negligence is malpractice and professional malpractice is not necessarily negligent.

Dr. A. Leon C. mentioned diagnosis or therapy errors in the same chapter of malpractice and negligence, and bracketed both errors into de "honest (diagnosis or therapy) error" concept. This "honest error" concept derives from the following: "The physician can not be considered infallible or guarantee patient recovery, even more when there is a critical condition or symptoms are confuse. Under these circumstances, the error can not be synonymous of negligence". Up to here what we know that "medical error" can be. Let us look now at some samples of current "errors".

The Joint Commission on Accreditation of Healthcare Organizations in the United States gave the second alert in three years last December 2001, intended to reduce the number of surgical errors in that country. The first alert had failed, so this second alert was aimed to the public (patients) asking them to demand that the surgeon clearly mark the site of the future surgery, and should the surgeon not agree, then the patient should mark the site by themselves. The second alert also asked patients to mark the site not to be operated on. Since 1966, at least 150 surgeries had been performed on non-affected body sites and even on the wrong patient. According to an American Academy of Orthopedic Surgeons representative, their members have 25% probability to operate on the wrong site, at least once, along 25 years of surgical practice.

Diagnosis error is also frequent for epilepsy. It was recently shown that a high percentage of children and adolescents were diagnosed of having epilepsy based on the loss of consciousness and EEG abnormalities criteria, which are present in 20% of normal people, for unknown reasons. Does this error high incidence make it less error, more susceptible to oblivion, dissimulation, concealment, legal and deontological sanction? From the legal point of view, non even once is acceptable. Although errors will never disappear from clinical practice or any other human tasks, errors are just not acceptable. There can not be tolerance with errors. Errors exist, they must be studied and analyzed in depth, and the target can not be other than their disappearance. Error acceptable statistics can not be admitted. The fact that errors occur does not mean that their recurrence is accepted. Accepting such thing is negligence.

Every medical error must be followed by a response, which introduces a correction and prevention factor into the medical practice. Medical audits and meetings to study morbidity and mortality are the instruments we have to take those actions.

Evolution and development of medicine has been the result of the joint work of teams, organizations and medical care systems.

Criteria of the physician individual responsibility still remain as an ethical value. However, this individual responsibility, which fosters medical practice in solitary, is becoming morally inadequate because isolates the physician from the team, organization and medical care system. To this effect, some important steps have been taken, as the ethical principles and norms that the Tavistock Group issued in 1999 - applicable to the physician, healthcare team, organizations and healthcare systems - under the global premise that every actor of the healthcare providing service is responsible to help and improve the service they provide.

The Tavistock Group ethical principle sets forth the evolution of ethics from the individual responsibility to the shared responsibility, another ethics that values patient safety and service-providing quality improvement. Such setting obliges the physician, and all service-providing stratum where he/she acts, to adopt an inquisitive attitude of constant vigilance, firmness in service-providing rules and norms, and continuous improvement of professional knowledge and necessary expertise.

Minimization of the potential for error in any of the areas of the medical or surgical duty is the aim, the expectation. The demand is the immediate divulgation of the error, in order to clearly establish the causes, motivations and event chain that conditioned the error, and, therefore, regulate and set in order the sequence of medical acts to avoid the error recurrence. Non divulging the committed error is a serious lack of respect for patient's rights, for obligations to the patients and people in general, and, now we know, for medicine it-self and those who practice it.

For centuries, doctors used to conceal and dissimulate to fight against individual or collective shame and penalties - which based on the Tailon Law and others equal or worse - that made physicians responsible for their medical actions when the results were different from those expected. Current Medicine advances and human right codes in force have resulted in a more adequate defense of people rights and a more general or even collective appreciation of the medical-surgical practice. Logically, medical-surgical practice appreciation would become very slurred if it was made public that medical fraternity, more than a community of unselfish and altruistic servers for ill human beings, is an accomplice society, whose members protect and conceal their errors among them, instead of learning individually or collectively from those errors.

Error punishment by means of shame, rejection, guilt exaggeration, extraordinary and disproportionate sanctions results in just what we want to avoid: concealment, dissimulation, affectation, etc. That was the way we used to live, when the fear to legal sanction impeded to study the whys and take the corrective actions, generating the vicious circle we have just described.

We are now in the face of a new setting. We have to act in favor of the best medical-surgical care and the highest patient satisfaction. However, the patient will have to recognize, as in fact he/she does, that we are humans and it is for humans to err. But we are also doctors and, therefore, we try not to err our professional actions. If such a thing happened, help should come out the error for other people because doctors as a whole would assume the duty to study what happened and how to avoid the error in the future.

Chapter News and Activities

  1. Annual Meeting Postponed. Due to the political situation in the country, the Chapter Advisory Council decided to postpone the Annual Meeting, which should have been held on May 23rd-25th, until September 5th-7th; in the same place and with the same program as published in Bulletin No. 3.

  2. Evergreen Award. ACP-ASIM Chapter Sub-Committee, coordinated by Dr. William E Dismukes, forwarded a communication to notify that Evergreen Award (for the Chapter Work on Scientific Meetings with Associates [Residents]) should be considered for next year, after demonstrating that the program has been maintained and that the Associates Members have increased.

  3. Associate Meetings. The Chapter is going on with Associate meetings at hospitals with Postgraduate Residencies. Three successful meetings have been held up to now. The last one (04-26-2002), at Hospital Militar "Carlos Arvelo", was coordinated by Dr. María Cristina Blanco and addressed the topic "Hormonal Replacement Therapy" as a controversy. Residents showed an excellent training, which ensured de conference success. Dr. Arístides Avila, Postgraduate Studies Director at Hospital Miguel Pérez Carreño, gave an excellent talk in the meeting, entitled "Doctor's Attitude in Face of the Terminal Patient". Congratulations to everybody. Next Meeting will be held on June 28, 2002, at Hospital Vargas, and will be coordinated by Dr. Hernán Wuani, ACP-ASIM Member, and Dr. Dimas Hernández.

  4. Insurance. In the assembly convened to analyze the Insurance Company offers to take out a collective insurance, it was unanimously agreed to authorize BMI Company to interview each individual Chapter Member in order to achieve the necessary number to contract the policy.

  5. Voluntary Service. Gatherings have been carried out with some Chapter Committee Coordinators (Scientific Activities, Ethics, Investigation, Computer Science, Voluntary Service) to study in depth the Voluntary Service and Service to the Community Project, which involves giving Primary Health-Care assistance, free of charge, at some institutions. This assistance will depend directly on the Venezuelan Chapter. Information will be provided on the results of these gatherings and the start of the activity.

  6. Joint Scientific Event. ACP-ASIM Venezuelan Chapter, as it is interested to project its activities inland, contacted SVMI Táchira Chapter to carry out a joint Scientific Event, which will be programmed and announced in our next Bulletin.

  7. Thank You. We wish to thank ACP-ASIM Foundation, by means of its management and Ms. Alice Coyle, for their $2,500 contribution to finance the Annual Chapter Meeting to be held 0n September 5-7, 2002.

  8. Mini-fellowship Program. Reinitiating Mini-fellowship Programs in the Venezuela Chapter seems to be a reality. Dr. Antonio Delgado, ACP-ASIM Member, has been granted a 2 to 3 month assistantship at Ann Arbor (Michigan) to deepen his knowledge on high blood pressure. This program is made possible, thanks to the support by Merck-Sharp & Dohme. We sincerely thank this support.

The Doctor and The Patient: The Metamorphosis of a Relationship

Rafael Muci Mendoza, MD, FACP

"Doctors rarely cure, some times give relieve but always console."

This epitaph, 14 centuries old, inscribed on Trudeau tomb at Saranac, captures the humanitarian treatment importance in medicine; we will see as posterior scientific prejudices have lessen human value to the interaction of a doctor with his/her patient, and therefore, the reason d'être physician.

Apollo was considered the God of Plagues and Diseases in their different forms. He invented Medicine and transmitted it to his son Esculapio (Asclepios). Apollo defended moderation in everything ("nothing in excess"), and advised the understanding of the own person ("know yourself"). Apollo was also the God of Music and Poetry, he perfected the lira invented by Mercury, by means of which he calmed the soul, moved the stones and tamed wild animals. Hippocrates de Cos was the father of Scientific Medicine, the most humane mankind activity, and it became accepted that our profession was science with an enormous art component. The use of the word, of dialog with curative purposes played an essential function in Greek medicine. Let us accept, thus, that our profession, due to its classic duty and by tradition, has been a liberal and humanitarian occupation since its origin. Hence, Doctors have been regarded as superior individuals dedicated to the service of defenseless humankind, totally released from trade and, when the time comes, willing to the loftiest sacrifices.

Perhaps since industrial revolution, technicality penetrates all human life facets and, in a formidable way, medicine. This offered a quality of life improvement, allowed to probe the most hidden rugged paths of human body and the physiologic comprehension of human body functioning, in health and disease conditions. However, due to above-mentioned events, the total and indivisible ill human being has been atomized in disconnected isles. This is the way the specialist arises, a dehumanized technician who despises art, considers the ill person as a thing, and seeks to obtain from his/her profession the pecuniary earnings for his/her own and family survival.

This search for earnings, not condemnable at all, is with notable frequency unbounded, loosing this way the necessary equilibrium point. How shocking this brief introduction to nowadays doctors can be, when 25 centuries of history have almost completely finished with the superior attributes of devotion and altruism, and with any attempt to employ the word to cure! How used we are to regard medicine as a highly technical and depersonalized science, when health is a matter of sale and disease subject to speculation.

Slowly, doctors, as beings who belong to a materialistic society, have been loosing their identity, now ruled by public or private hospital industry caprice, the market technical knowledge of the multinational pharmaceutical companies, or the automated lab equipment or diagnostic devices manufacturers of the most complex sort. Doctors found themselves in disadvantaged pugilism against the wise moderation that calls for a diagnosis made by secure, simple, and less onerous or painful ways. Doctors have been graduated in increasing quantities, not related with the real necessities, in many Latin American countries, under capricious study plans influenced by rare ideologies, detached from doctors' functions, which end to be humanitarian. And it is that medicine is not taught by anybody, medicine is only acquired by a serious learning and is a never-ending task of eminently personal nature.

That is what we must teach our students. Dazzled by scientific advance.

New Addresses/How to Contact Us

Governor-
Israel Montes de Oca

Address-

Home:
Avenida las Acacias
Edf. Albarregas 71
La Florida
Caracas, Venezuela

Office:
Centro Médico de San Bernardino
Anexo B, 2° piso-C
San Bernardino
Caracas, Venezuela

Mailing Address:

In Caracas:
Apartado Postal N° 1126
Caracas 1010a
Venezuela

In Miami:

1.USPS: P.O. Box Mail in USA
CCS 5253
P.O. Box 025323
Miami, Fl 33102-5323

2. Courier: physical Address for (Package or Bulk) in U.S.A.
CCA5253
4440 NW 73 Av.
Miami, Fl 33166

Phone Numbers:

Home: 058 (212) 781-2992
Office: 058 (212) 551-5442
University: 058 (212) 662-8202
Cellular: (0414) 303-1005

E-mail: imontes@reaccium.ve

NOTE: Opinions expressed in articles in this issue by collaborators are not necessarily that of the Chapter Board of Directors.

The English version of this Newsletter is courtesy of Merck Sharp & Dohm Laboratories.

Contact Information

Aquiles R. Salas, MD, FACP
Governor, Venezuela Chapter

Susana Teruel
Venezuela Chapter Executive Director
Prolong Calle Sucre
Edif. Rias Bajas, No. 9D
Chacao, Caracas, Venezuela
Phone: (58) 212-261-6076