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Venezuela Chapter Governor's Newsletter
March 2002

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

Editorial: The Horizons of Internal Medicine

The challenges that the contemporary medicine confronts are present, more and more, due essentially to the development of a basic science applied with more interest to the profound knowledge of disease's mechanisms that helps the clinician understand his responsibility in obtaining that information through different means. It has not happened the same with the progress of the humanistic aspect of the profession, which has been left behind in aspects such as the thought and the individual's anguish. Not enough has been written about suffering and other facts that cause it, in contrast with the huge possibilities of a being's complaints, to whom the primary aim is to seek comprehensive help from medical assistantship.

The internal medical doctors, prepared in holistic medicine -Internal medicine as scientific and humanistic specialty -, cannot withdraw in these times of identity changes and, must become the specialist of excellence who is able to combine the two main currents that cause the development of a great spectrum of diseases, from the simplest to the most complex ones.

This mean of information, for members of ACP-ASIM from Chapter Venezuela, is aimed to reinforce, based on opinions, the previously mentioned concepts, and at the time same consolidate goals and mission of this medical association.

Today we are pleased with the essays written by members of this chapter such as: 'El Internista en el siglo XX' by Dr. Carlos Moros Ghersi, mentor of many generations of internal medicine doctors; 'Informática médica' by Pedro Perdomo, outstanding medical doctor and, 2nd part of topics of 'Etica Médica' by Dr. Alvaro Requena, outstanding psychiatrist of whom the Chapter is proud to have among its members.

The profound matter of these aforementioned articles, is an example of what we can achieve by adding orthodoxy from continuous and modern education of the specialty in holistic internal medicine and the superspecialties derived from them.

We would like to invite all members of Chapter Venezuela to our Annual Meeting to be held by May 23rd - 25th, 2002 for generalist physicians and superspecialists of the Chapter. The program is summarized and enclosed in this publication.

This event fulfills one of the objectives of the ACP-ASIM as it is the continuing medical education in order to move toward excellent professionalism.

Finally, a thought from Dr. William J. Halle (FACP-ASIM), current president of this association recorded in The Observer: "Our impact on patients is determined by both, what we are and what we know".

The internist in the XXI century Dr. Carlos Moros-Ghersi, FACP-ASIM, former president of SVMI and former rector of UCV.

In spite of difficulties that internal medicine confronted in some countries, Venezuela among them, to be implemented by health services, it is a fact - as it can be verify through significant experiences en various nations, this services will be progressively requested as health services develop to respond to the challenges and evolution of XXI century medicine. Indeed, this century is characterized by an significant increment in the medical knowledge that will make possible deep understanding of illnesses, the existence of advanced technologies for the patients diagnosis and treatments, as well as, the preventive measures of great value.

Substantial changes will take place as a consequence of these progresses, among them, those regarding prevention - which will reach exceptional goals- and the diagnostic and treatment methods -which will rise impressive results in their application to the patients- building up a substantial improvement in health and in consequence beneficial effects on the individual and society's quality of life.

Nevertheless these asseverations, that medicine endowed with wide powers outlines several and important problems.

In first place the possibility of overcoming utopia to make it reality, in the context of health services costs and the budget assigned to this sector, since even though in some countries with elevated inversions in the health area, it makes evident that the problem derived from implementing a medicine conceived like this because of the high cost that it represents and, of course, its applicability is highly difficult when the budgets are insufficient and there are deep economic and social inequalities among its inhabitants, like it happens in underdeveloped countries.

If it cannot be overcome in the future, the balance between covering / equity and quality, service, on the base of the new scientific advances for the entire community, those of less resources will be excluded; those won't have access to them, as it is already happening, fact that is against the basic postulates of the medicine.

Indeed, as we pointed out in a previous work, in agreement with Dalen (2000), in USA 1998, the investment in health was 1.2 trillions of dollars, the highest in the planet. A significant reason for this huge investment was the introduction of new and very effective, but also very expensive, diagnosis and therapeutics procedures. As a consequence of that situation, the administrators and the users found that they couldn't afford the health assurance; for this reason the uninsured people -which in 1999 represented 44 millions of individuals- begun to increase.

Moreover, apart from various causes that effectively encourages exaggerated use of modern technological resources, to support the diagnosis, like it happens with the so-called defensive medicine, used as a protection media from possible sue for malpractice. There are definite evidences that this fact is a consequence of the direction of those diagnostic methods without a correct application of the clinical procedures, which demands that the complementary exams -except those which obey to explorations linked to prevention- take place in agreement with the clinical diagnosis and, in by no means become substitutes of intellectual reasoning derived from the clinical history application.

The rationality in the use of the complex and expensive exams has been this way object of attention of diverse societies and scientific groups because, if such substantial changes in this aspect does not occur, its expensive cost, like the one signaled by Dalen in USA, about the millions of people uninsured, a massive exclusion of dense sectors of the society, of its , will take place.

For that reason, although it seems paradoxical, the viability in the application of those advances in the population's totality will be feasible, only if, an excellent clinical exam will take place, based on a dense and detailed clinical history and the consequent diagnosis.

The internists have had in the clinical history its more powerful tool. They are trained to accomplish a professional practice in which the exploration's relevance related with the diagnostic progress constitutes one of the specialty's clues. That characteristic allows him to be an essential filter and a guide for the own use and interpretation of the complementary exploration, with the certainty that the unnecessary exams, produce more exams, that drifting into an uncontrollable situation that can obscure the diagnosis.

Furthermore, if for these proven reasons, the Internist becomes recognized as like one of the most suitable specialists of the XXI century medicine in the signaled framework, other characteristics of their professional practice will make him/her more necessary. In first term, among others, the spectrum of their exercise is applicable to a large sector of the population assisting people from the adolescence to senility and second, that it doesn't limit its activity to certain illnesses but rather, people with varied and numerous consultation motives can request their services. Finally, in their medical work they assume the continuity in the attention that she/he lends toward the patient -despite when she/he requests inter-specialties check ups - and may extend that activity to the family and social environment.

But, in addition, the internist completes its role of the aforementioned aspects with another attribute required by the health system, its problem solving capacity toward the patients that he assists. Indeed, it is desirable that in the third care level of attention, the hospital can be devoted to the functions for which it is destined but, does not become crowded with patients, the majority of whom can resolve their ailments in the first or second level of medical attention. The internist's action, at the three levels, is guaranteed by postgraduate staff which confers to the system, the demanded problem solving capacity, efficiency and effectiveness, that this matter needs and makes true the possibility to obtain the quality of attention in a beneficial relation investment/ cost.

The effects of those internist's qualifications should be estimated, but regrettably, in spite of the high number of graduate schools of internal medicine, in our country, the numerous groups of graduates do not find any place that allows them to develop their skills due to the scarcity of internist's vacancies, propitiating by this way, the under utilization with the repercussions of this fact upon the health system. A second aspect regarding the current century's needs of internists has to deal with the characteristics the medical attention must fulfill conducted by the application of the previously described innovations, consequences of the scientific and technological impact on the professional practice. Certainly, as pointed out by Fletcher / Fletcher, the future diagnostics will be easier and more accurate as effect of the technological advances in genetics and molecular biology; the genetic maps will reveal the increased susceptibility to diseases. The imagenology would visualize almost the whole internal anatomy, without physical invasion to the body and, the scans would expose the chemical components of the organism. The diagnosis and treatments will be less invasive and the computarized information will produce the exact knowledge that demands this issue.

If you could arrive and transform, in those terms, the medical practice in reality and could arrive to the application of all the goals described by the mentioned authors, the utmost think that will be require in the future will be expert clinicians charged with a big capacity for integrating and produce.

Really, if the medical practice would change in the described terms and we will reach for all of us the application of the outlined goals by the aforementioned authors, in the future, clinical experts will be the most necessary; physicians endowed with great capacity to integrate and produce an adequate balance of complex information that impacts the medical practice; someone with skills to explain a stream of advances and visualize them in a comprehensive approach toward wise decision. The medical practice, moreover, could not be limited to an specific aspect, but it would have to take them into account all aspects: diseases biology, the social-economic environment and the specific patient's conditions and his preferences.

Among the challenges that internal medicine will face, the most relevant - besides clinical expertise - will be the capacity to dig into new disciplines, as well as dealing with information, new roles in clinical epidemiology, behavioral medicine, the economic aspects of medicine and ethics.

Without any doubts, as it has been acknowledge by various authors, many of these expected attributes of physicians of this century are those that internists have shown throughout long time and that represents traditional values of internal medicine as specialty.

From there, in spite of the super-specialization process that has happen with graduates students in many countries, including Venezuela, the true future need of internal medicine will be preserve and broaden its role as generalist. As Fletcher & Fletcher have stated, internal medicine will perform a leading role under the holistic view, basic view of scientific societies such as ours 'Sociedad Venezolana de Medicina Interna', but not base on fragmentation thus making it play a peripheral role in this scene, introducing obviously, in its practice, the required systemic changes to accurately respond to highly competent generalist future needs.

For all the aforementioned, we believe that our 'Sociedad Venezolana de Medicina Interna' and the 'American College of Physicians Región-Venezuela' will have to focus its activities in order to optimize its mechanisms to enhance our competencies to fulfill the internist generalist future needs.

News of the Chapter and School

1. - The Región Venezuela will receive, in the next Annual Meeting of the School to be carried out in Philadelphia April 2002, the prize to the Conduction of the Chapter for the period 2001-2002 (Chapter Management Award), where the work of the Dr. Ramón Soto, Governor in that period, made possible this recognition. Congratulations to all our Members.

2. - Mr. Alex Nalencz has been designated as new International Administrator as substitute of Miss Emily Brooks. The Members of the Chapter that want to make consultation can go to the following electronic address.
< analencz@acponline.org >

3. - The Members can fill a form to actualize their registration in the School.

4. - During the Annual Meeting of the School (April 2002) 27 Resolutions will be discussed, all very important ones, among them: New Name for ACP-ASIM and others of interest for the medical practice of the Internists. They can be known through the School Web page.

5. - The School coordinates in its program "Reports of Internal Medicine" (Internal Medicine Report), a TV series about videos concerning different Internal Medicine topics. It can be seen in the page http://www.doctorsforadults.com/im_report.htm.

6.- In the Región Venezuela Web page, it appears the details of a new program that provides the behavior resources for the medical practice. ("Practice Management Center). Also can go through www.acponline.org/cln/general/pm_webpage.htm

Medical Informatics: Dr. Pedro Perdomo Miteff (ACP-ASIM member)

Based on understanding that physiology literally means 'logic of life'; pathology means 'logic of sickness' thus, medical informatics would mean 'logic of health care'. It is the rational study of the way we reckon about a patients, the way treatment are defined, chosen and develop and, at last it is the study of how we plan to create and to make heath systems work.

The sprout of medical informatics as a new discipline is due to great extend to the fast advances in computation technology and communications, but it should not come us a surprise that even though this term was first used in 1973, the idea could be as old as medicine itself, it is born the day that a medical doctor took first notes of his impressions of a patients sickness and he use them to learn from them for the coming future patient. There isn't any doubt that what has changed is the potential to describe and manipulate the medical knowledge to high levels of abstraction - applied statistics, - as well as the aptitude to make system able to store and transport this amount of knowledge - Internet, specific webs sites, internet2-. All this would be practically impossible to achieve thanks to traditional methods that utilise paper as a mean.

The medical informatics is a science indeed, that holds the following characteristics:

It has ownership over a territory or area and, it is determined by the intersection of terms such as 'medicine' and 'informatics' or 'health' and 'information'. The first represents the area of investigation and the second, its methodology

It is not only an applied science since it includes theoretical basis besides the applied ones.

It develops models for applications as well as theoretical activities; therefore, it is not only determined by technology.

Problems solve itself in theoretical ways, following scientific principles of abstraction and generalization.

In this discipline, methods are developed and evaluated in order to acquire, process and interpret the patient's data, thanks to the knowledge acquired in the scientific investigation.

The PC's are the vehicles to achieve such a goal; these tools are for the medical informatics what stethoscopes are to cardiology. As PC's prices go down and more powerful computers are developed with great storage capacity, they become instruments that no physician can do without. This equipment, however, should not be regarded as the ultimate goal, but on the contrary as a mean to achieve the best possible health of care. It would be tedious mention all areas related to this discipline; as example we will mention: data processing, databases, telecommunications, webs, codes, medical histories, biosignal analysis, processing analysis and storage of medical images, information system pertain to a specific patient such as primary care, nursing, clinical departments, etc., strategies to acquire further knowledge, decision making, education, medical training, curriculum development so on and so forth.

However, most likely one of the most relevant aspect, encouraged mainly by internet, is the opportunity to access, to medical information, to the general public and the acknowledgement of the natural right of one becoming active actor of his own guard.

Topics On Medical Ethics (II): Dr. Alvaro G. Requena (Miembro ACP-ASIM)

Imputations on certain physician's practices that may be considered oppose to professional ethics.

Conflict of interest: A few years ago independent publications with no advertisement, used to be guarantee. Today it is not the case anymore, whoever writes or publishes might be an interested part and, by failing to make it known, one could take it for granted as a fair as just and appropriate, of work that could biased, insufficient and devious.

Being in conflict of interest, and make it known, does not invalidate anyone or his work, but it has to be stated, moreover everybody must demand it to be declare. Nowadays most medical journals in the world demands to the collaborators their declaration of conflict of interest, in the understanding that having this type of conflict is nothing wrong or something to be ashamed of. It only describes a situation that guides the reader regarding the sources and other asseverations.

Recently, problems raised due to conflict of interest upon publication about phenfluramine on lung circulation, and how a delay in clarifying it, brought along delay to perceive the possible clinical damage. If those authors that denied effect or minimise it would have declared their relationship with the pharmaceutical lab that manufactures this product, sooner not later, this would have been known; or at least it would have been suspected.

Nowadays, there are many medical periodicals that demand that a conflict of interest must be declared, obligations with commercials related to the health surroundings. Also, it is expected from research sponsors and publicity space, a written release of all kind of responsibility regarding to all economic support.

More and more is frequently considered, that the true owners and responsible for the stated statements, and the published works, are the researchers but not the companies that have sponsored their research. Obviously in the specific case of researches done by sponsor employee the first mentioned is the owner, but a statement of conflict of interest would clarify the situation. Therefore, our conclusions would not have been mislead by any doubts.

Hence we consider that the medical profession, and scientist in general, are progressively demanding absolute responsibility for the authors of scientific publications. This includes researchers, writers and sponsors. The above should include, as soon as possible, both the control and obligation to publish research whose expected hypotheses were not as expected or which results were not adequate for future marketing of a product. This attitude championed by some of the most prestigious medical journals reflects the discontent and insecurity that many physicians have been suffering, especially by those who maintain themselves up to date in the profession by means of publications.

We wish to read, besides the published articles, the acquiescence of responsibility for the published concepts, the declaration of the independence, of the authors and their sponsors, and their acknowledgement that they had access to complete information on the research procedures and findings, as well as of their right to publish the findings, data and related information to their research, without limitations.

American College of Physicians-American Society of Internal Medicine (ACP-ASIM)

Chapter Venezuela. IX Scientific Meeting. Annual Program.

Site: Hotel Hilton Caracas. Dates: May 23rd, 24th and 25th, 2002. Promoted by: Pan-American and Iberian Federation of Societies of Critical Medicine and Intensive Therapy, Venezuelan Society of Internal Medicine, Venezuelan Society of Critical Medicine, Latin American Society of Internal Medicine (Solami).

"Role of the Internist in Acute Disease and Critical Medicine."

Wednesday, May 22: Inscriptions (Register)

Thursday, May 23: Inscriptions (Register)

Session A. - CHAIRMAN: Moisés Narváez M.D

Welcome: Israel Montes de Oca MD. Governor Venezuela Chapter ACP-ASIM
(FACP-ASIM).
Coronary Disease: New Concepts and Treatment. Dr. Harry Acquatella.
Invasive Cardiology: When and How?. Dr. Francisco Tortoledo.
Steroids in Acute Cares in 2002. Dr. Richard Carlson.
News from ACP-ASIM (College Representative). Dr. Stephen Beutell.

State of the Art. CHAIRMAN: Rafael Dávila M.D

Revising ABC of Cardiopulmonary Resuscitation. Max Harry Weil MD.

Lunch conference. CHAIRMAN: Dr. Pedro Andrade.

Session B. - CHAIRMAN: Dr. Mario Ogni.

Pulmonary Tromboembolism. Advances in Diagnostic and Treatment. José López Antonini M.D.
Chronic Obstructive Pulmonary disease with Acute exacerbations. Douglas Olivares M.D.
Non-Invasive Mechanical Ventilation. Janice Zimmerman M.D.
Pneumonia: Community and Nosocomial Acquired: Diagnostic and Treatment. Raúl Isturiz M.D.

Session C. - CHAIRMAN: Gabriel D' Empaire M.D.

Acute Crisis in Bronchial Asthma (Status Asthmaticus) New Therapeutic Trends. Federico Capriles M.D.
The Diagnostic and Therapeutic Importance of Hypercapnia during Acute Circulatory Failure. Max Harry Weil M.D.
Acute Respiratory Failure Syndrome XXI Century. Richard Carlson M.D.

State of the Art. CHAIRMAN: Dr. Francisco Fragachán.

Hypertensive Emergencies. Janice Zimmerman M.D.

Friday 24th May.

Symposium. CHAIRMAN: Dr. Héctor Marcano (SVMI -President).

Sepsis, Septic Syndrome, SRIS and Shock: update concepts. Max Harry Weil M.D.
Diagnostic Difficulties of Sepsis and Septic Shock. Janice Zimmerman M.D.
Update on Sepsis Treatments. Richard Carlson M.D.

Session D. - CHAIRMAN: Trina Navas M.D.

New Antibiotics. Manuel Guzmán M.D.
Bleeding and Coagulation Disorders in Acute Clinical Events. Dra. Janice Zimmerman.

Session E. - CHAIRMAN: Mario Patiño M.D.

Paper presentations of Awards Research (Especial Residents Meeting. SVMI (2001). Questions and Answers.

State of the Art. CHAIRMAN: Hernán Trujillo M.D.

Treatment of Metabolic acidosis. Max Harry Weil M.D.

Lunch with Expert. CHAIRMAN: Dra. Vivian Sukerman.

Session F. - CHAIRMAN: Imperia Brajkovich M.D.

Diabetes Mellitus. Acute Complications. Claudio Urosa M.D.
Treatment of Endocranial Hypertension in critical situation according to Medicine based on Evidence. José Besso M.D.
Acid-base Equilibrium in acutely ill patient. César Prú M.D.
Acute Adrenal Failure. Stephen Beutell. M.D.

State of the Art. CHAIRMAN: Anabell Arends M.D.

Therapeutic Innovation to patient Anemia in the UCI. Richard Carlson M.D.

Anatomicoclinical Discussion. CHAIRMAN:Conny García M.D.

Discussion: Rafael Muci Mendoza M.D.
Pathologist: Dr. Luis Gonzalo Gómez.

Saturday 25th May:

Breakfast with Expert. CHAIRMAN: Guillermo Boggiano M.D.

Session G. - CHAIRMAN: Ricardo Serbanescu M.D.

Acute intoxication due to drug and psychotropics abuse. Janice Zimmerman M.D.
Ketoacidosis Syndrome. Richard Carlson M.D.
Acute Renal Failure: Management José Weissinger M.D.
Acute Abdominal Pain. Management. Eddie Kaswan M.D.

Session H. - CHAIRMAN: José Martínez Pino M.D.

Automated External Defibrillator. Max Harry Weil M.D.
Intensive Care in Obstetric Pathology Patients. Ramón Soto M.D.
Parenteral Nutrition in Critical Patient. Eva Essenfeld of Sekler M.D

Session I. - CHAIRMAN: Guadalupe Urdaneta M.D.

Imagenology in acute conditions and critically ill: Echosonography, X-ray, CAT, Magnetic Resonance.

CHAIRMAN: Dra. Ana Gascue.

Advances in Stroke Treatment Marcos Troccoli M.D.
Acute Endocarditis. Eduardo Morales.M.D.

CHAIRMAN: Dr. Israel Montes de Oca (Governor FACP-ASIM).

Delivery of Awards and Certificates. Internist of the year. Volunteerism and Community Service. Posters of Associates and Students.

Organization of the Event: Tanya Lasses Organization of Eventos Telephone numbers : 58+(212)986 2057. Cel. 58+(414) 2495559. E-mail: Tanya-lasses@cantv.net.

Contacting Us

Governor: Israel Montes de Oca.

Address: Hab. Avenida Las Acacias Edificio Albarregas 71. The Florida. Caracas, Venezuela. Telephone: 58 (212)781 2992. Office: Center Médico de San Bernardino. Anexo B 2º floor-C. San Bernardino Caracas, Venezuela. Telephone: 58+(212)5515442. Postcard Address: Caracas: Apartado Postal Nº 1126. Caracas 1010.Venezuela. Miami: 4405NW 73rd. Ave Suite Nº 30-837. Miami Fl. 33166-6400. University Teléfonos: 58+(212)-6628202. Cel: 58+(414)-3031005. E-mails: imontes@reacciun.

Notes:

  1. The concepts emitted in the opinion articles are of their authors' direct responsibility and not necessarily of the editorial staff of Región-Venezuela.
  2. This Bulletin (Newsletter) has been published in Spanish and English thanks to the cooperation of Laboratorio Merck Sharp & Dohme.

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