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July 2011


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Internal Medicine: Global Perspectives

Jaime C. Montoya, MD, FACP
President, Philippine College of Physicians

The Philippine College of Physicians is a world class organization of physicians that sets the highest standards and ethical ideals in the practice of Internal Medicine and provides dynamic leadership in the promotion of health and quality of life in the management of disease and in the formulation of relevant health policies. The organization provides continuing medical education of internists and other physicians; certification and regulation of the subspecialty of internal medicine; and accreditation and certification of the training programs for internal medicine in the Philippines.

What inspired you to become a physician?

In the Philippines, a physician is highly regarded in the community not only for his integrity and dedication to vocation but also because of the services rendered at the highest level to the community. Each Filipino family would dream of having a son or a daughter to pursue a career in medicine. In addition to the high social regard for medicine in Philippine society, I was also encouraged to become a physician by my uncle who is a kidney surgeon. I looked up to him as a role model for his successful practice as a physician and surgeon, the admiration of satisfied patients and recognition among peers and colleagues for his health advocacies in the community.

What is the role of “internist” in the Philippines? What do people expect and want from their internists?

Internists are recognized as doctors for adults in the Philippines. In different parts of the country, particularly in the underserved areas distant from the urban centers, internists are much needed in providing critical and essential medical care. They are relied upon to provide immediate, appropriate and affordable health care especially in emergency situations and also during disasters and natural calamities like typhoons and earthquakes. They are also depended upon to provide accurate and reliable information on ways of preventing disease in the community.

Are there special challenges facing internists in the Philippines? What are your thoughts on the best way to meet those challenges?

There are many challenges in the practice of internal medicine in the Philippines. Among these challenges is the lack of a much needed and critical health infrastructure like well-equipped health care facilities particularly in the peripheral and remote areas of the country. It therefore becomes very difficult for internists to practice and deliver optimal health care to patients in these areas.

The lack of appropriate remuneration particularly for internists working in government facilities is also a challenge. The income of government internists who are called “medical specialists” is barely enough to help them survive, much less to raise a family. They will therefore prefer to work as private doctors or prefer to work in the city where opportunities for income are better.

It is difficult for physicians to access continuing professional education in remote due to the considerable distance of doctors from training centers and the absence of internet facilities. There is therefore increasing difficulty for internists to update their professional competence.

There is an increasing emphasis on subspecialty training (e.g. cardiology, endocrinology) to the detriment of the practice of general internal medicine. As a consequence, medical care is becoming more and more specialized and the holistic approach to health care is waning and being lost.

Those physicians who have finished an accredited training program in internal medicine but did not pass the specialty board in internal medicine have organized their own group that threatens to break away from the PCP (Philippine College of Physicians).

The Philippine College of Physicians is therefore proposing and implementing a number of strategies to encourage internists in their practice. We are creating and updating a national health manpower database together with the manpower group of the Department of Health with vital information on site of practice of active internists so that we can identify areas where there are no internists. With this information, we can advertise these positions to our young internists. We are providing financial assistance to beginning and young internists who are just establishing a practice, especially in the far flung areas. This will hopefully encourage them to practice in these areas.

We are establishing CME online utilizing the internet with appropriate credits for members so that doctors who have difficulty attending seminars and symposia due to distance can get professional updates and CME credits. Due to the devolved health care system in the country, we are meeting with local governments to give better pay to internists and motivate them to stay and deliver much needed health care in their communities.

We have established the Philippine Society of General Internal Medicine (PSGIM) to provide for and to attend to the special concerns of practicing internists in the country. The different subspecialties have their own respective organizations but internal medicine does not have one other than the PCP which is the umbrella organization for internal medicine and all of its subspecialties in the country. The PSGIM will be working closely with the Philippine College of Physicians in fostering and advancing the cause of internal medicine.

We have been working closely with the Philippine Health Insurance Corporation which is the national health insurance corporation of the country to provide a higher and more commensurate professional fee for internists and also physicians who have graduated from an accredited training program in internal medicine. Although the latter group will not get a fee as high as the diplomats who passed the specialty boards, they will at least get a higher fee compared to the general practitioners or those who have not taken further training.

The provision of higher pay for internists and those who finish an accredited training program in internal medicine by the Philippine Health Insurance Corporation as well as the loss of accreditation from the Philippine Medical Association of the group of doctors who do not pass the specialty boards, have helped address the impending break away of these doctors from the PCP.

Constitutional amendments such as the creation of seats in the board of regents for representatives coming from the region will provide the chapters from the region a louder voice in the board to raise their concerns and propose appropriate solutions to these issues.

What are the most common chronic illnesses and how do they affect the day-to-day job of an internist?

The most common chronic illnesses based on the morbidity and mortality statistics of the Department of Health include cardiovascular diseases such as hypertension and heart disease, diabetes mellitus, chronic pulmonary diseases such as chronic bronchitis and asthma, chronic kidney diseases and malignancies.

This means that internists and physicians should get updated information on these conditions as well as continuous improvement and development of other related skills such as the use and interpretation of diagnostic tests and more cost-effective modalities of treatment for these diseases.

Are there enough young physicians in the Philippines choosing to be internists? What makes them so? What are the barriers to entry?

Based on the data of the Philippine College of Physicians, there is approximately a yearly increase of about 10 percent in applicants for the specialty board in internal medicine. Although the annual passing rate for takers of the specialty board remains at about 50 to 60 percent, the specialty board exams are continually improving.

Delay in taking the specialty board by doctors after finishing the training program in internal medicine as well as the lack of board reviews constitute the most common causes for failure to pass the specialty boards in internal medicine. The PCP is now accrediting board review classes being offered by recognized institutions to adequately prepare the doctors for the specialty board exam.

Is there public debate about your country’s health care system?

The current debate now on the health care system is the need to provide universal health care to all Filipinos, particularly the underprivileged Filipino patients. Only 30% of the total health expenditure of the average Filipino is being paid for by the government with the remaining 70% being shouldered out of pocket by the patient. Moreover, public health services fail to cater to the poorest 20% of the population. This is a priority problem recognized by the current administration under the leadership of President Benigno Aquino III. Universal health care that will not require out of pocket spending for health care with accessible and appropriate health care services for all Filipinos is the foremost health goal of the Aquino administration.

Do you admire the health care systems of other countries and if so which ones and why?

In the Asian region, one of our most admired health care systems is the health care system in Sri Lanka which is already able to provide universal health care to all its citizens despite its limited budget. One of the best practices in Sri Lanka is the successful private public partnership in many health projects and activities as well as the provision of free health services to all with no out of pocket spending. Another admired health care system is the one of Thailand where the government is already spending more than one percent of the GDP on health care. The World Health Organization has already set a universal benchmark of at least one percent of the GDP to be spent on health.

What could other countries learn from health systems in the Philippines?

Despite the limited health budget in the Philippines, one of the most admired features of our health system is the essential role of community health volunteers or what we call the barangay health workers in the delivery of primary health care. They are community citizens who do not get remuneration but provide important health services. They have proven to be effective and engaged partners of the Department of Health in ensuring that the primary health care needs of Filipinos are met.

The successful development of local health technologies such as indigenous and traditional medicine in the delivery of health care is also an admired feature of our health care system. This has led to the development of cheaper and equally effective medicines such as the plant Vitex negundo for cough and asthma that has spurred the development of the local herbal medicine industry in the country. The Department of Science and Technology, through the Philippine Council for Health Research and Development, has also helped fabricate and develop local health care equipment that as much cheaper and equally effective as the imported versions.

Is there access to electronic information on products influencing what patients want from their doctors in the Philippines?

Yes. Although internet connectivity is still limited especially in remote areas of the country, patients are more health conscious and more aware of current health developments.

What are your responsibilities as president of the Philippine College of Physicians?

Being the President of the largest specialty organization in the country and the largest and only accredited umbrella organization of internal medicine specialists and subspecialists in the Philippines, I have to steward the organization with important tasks and significant responsibilities.

As President, I uphold the highest standards of the practice of internal medicine. I am the Chairman of the Board of Regents and the Philippine Specialty Board of Internal medicine. I am empowered to create committees to carry out the objectives and goals of the PCP.

I have to be the loudest voice and the strongest advocate for the cause of internal medicine and optimal health care for all Filipinos. I have to continually improve and build on the image of the Filipino internist to maintain the trust and confidence of the Filipino patient. I am also the leading strategist, negotiator and liaison with the Department of Health in addressing national, regional and global health concerns.

Does the Philippine College of Physicians have collaborative relationships with other societies and if so, is it beneficial to your society and how?

The Philippine College of Physicians is working with other specialty organization in the Philippines (e.g. Philippine Pediatric Society, Philippine College of Surgeons, Philippine Obstetrics and Gynecology Society and the Philippine Academy of Family Medicine) to develop and implement important health advocacies and projects such as the HERO project or Health Education Reform Order. The HERO seeks to develop instructional, evidence- based modules that will be used by teachers in disseminating health information to primary and secondary students in the country. These modules will eventually be integrated in the curriculum of primary and secondary education in the Philippines.

We are also working with government agencies such as the Department of Health and the Department of Environment and Natural Resources (DENR).We just had a Memorandum of Understanding with the DENR in the implementation of a National Tree Planting Program that will enable doctors to plant trees and contribute to the national efforts in addressing issues on climate change and environmental health.

The PCP, through the ASEAN Federation of Internal Medicine (AFIM), is partnering with the other internal medicine specialty organizations in the other member countries of ASEAN for the harmonization of standards in the practice of internal medicine as well as regional integration of internists in ASEAN. This effort is targeted for the ASEAN harmonization of internal medicine in 2015.

The PCP also hopes to work with the American College of Physicians in helping improve and upgrade the knowledge and skills of the Filipino internist that will ultimately lead to better quality health care services to Filipinos.

What have you found to be the most challenging part of this position? What have you found to be the most rewarding?

The most challenging part of my position is my meetings and negotiations with government agencies to ensure and protect the best interests of specialists and maintain the highest quality of health care for Filipino patients.

The most rewarding are the compliments and the word of thanks from patients and colleagues as well as recognition from government leaders for our valuable and important participation in health programs, projects and activities.

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Update Your Knowledge with MKSAP 15 Q & A

A 46-year-old man has a 1-year history of almost daily nonseasonal nasal congestion associated with a clear nasal discharge but without sneezing or itchy eyes. Symptoms are worse on humid days or days when the air quality is poor. There is no relationship to spicy foods. The patient has not had headache, facial pain or pressure, fatigue, malaise, fever, sore throat, cough, or change in sense of smell. Oral antihistamines do not relieve his symptoms, and he has not used any nasal sprays. Medical history is significant for hypertension managed with hydrochlorothiazide. There is no family history of asthma or hay fever.

Vital signs, including temperature, are normal. Examination of the nose shows only a clear mucoid discharge. The sclerae are not erythematous. The lungs are clear to auscultation.

Which of the following is the most likely diagnosis?

A. Allergic rhinitis
B. Chronic sinusitis
C. Chronic vasomotor rhinitis
D. Rhinitis medicamentosa

Click here for the answer and critique.

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International Meetings Update

ACP Chile Chapter Meeting
May 9-10, 2011

From left: Dr. Collier, Dr. Hood, and Dr. Pinto

The annual meeting of the ACP Chile Chapter was held May 9-10, 2011 in Santiago, Chile. Around 250 participants attended the meeting, with physicians attending from Argentina, El Salvador, Venezuela, the USA, and Uruguay. Around one quarter of the attendees were Associate members.

Virginia L. Hood, MBBS, MPH, FACP, President of the American College of Physicians, was the Leadership Liaison and Virginia U. Collier, MD, FACP, was the International Ambassador. They were invited to participate in the meeting by Maria E. Pinto, MD, FACP, Governor, ACP Chile Chapter.

Jose A. Rodriguez Portales, MD, FACP, received the ACP Laureate Award. The Chile Chapter also gave special awards to the following distinguished members: Juan Carlos Bagattini, MD, FACP from Uruguay; Luz Maria Letelier, MD, FACP; Dr. Hector Ugalde, MD, FACP; Jaime Labarca, MD, FACP; Andrés Aizman, MD; and Juan Cristobal Celis, MD, Past Chair, Associate Council, ACP Chile Chapter.

For more photos from the meeting, visit the Chile Chapter photo gallery

Annual Meeting of the Internal Medicine Society of Uruguay
May 13-14, 2011

The annual meeting of the Internal Medicine Society of Uruguay, entitled "Updates in Internal Medicine" was held May 13-14, 2011, in Montevideo, Uruguay. The meeting was held in conjunction with the British Hospital of Montevideo. Approximately 80 internists, residents, and some students from all over Uruguay attended the meeting. Two invited speakers from Argentina also participated as faculty in the meeting.

Virginia L. Hood, MBBS, MPH, FACP, President of the American College of Physicians, was invited as the ACP International Ambassador to the meeting by Juan Carlos Bagattini, MD, FACP, Course Director.

XIX Annual ACP Venezuela Chapter Meeting and Internal Medicine Society of Venezuela Congress
May 17-20, 2011

The annual meeting of the ACP Venezuela Chapter was held May 17-20, 2011, in Caracas, Venezuela. Robert Luke, MD, MACP, Immediate Past Chair, ACP Board of Regents, was the Leadership Liaison and William Hall, MD, MACP, served as the ACP Ambassador to the meeting. They were invited to participate in the meeting by Eva Essenfeld-Sekler, MD, FACP, Governor, ACP Venezuela Chapter. Dr. Luke presented on "Use and Abuse of Diuretics" and Dr. Hall presented an Update in Geriatrics. Both also gave an update presentation on news from ACP.

During the meeting, distinguished awards were presented. Carlos Goldstein, MD, FACP, received the Chapter Laureate Award and Gustavo Villasmil Prieto, MD, received the Volunteerism and Community Service Award (pictured at left, receiving their awards).

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Future World Wide Internal Medicine Meetings

The current list of Future World Wide Internal Medicine Meetings is available here. Upcoming meetings will be taking place in Colombia, Italy, and Greece.

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New International Fellows

ACP is pleased to announce the following newly elected International Fellows, who were recommended by the Credentials Committee and approved for election by the Board of Regents as of July 1, 2011. They are listed by current location and may have been credentialed through a different Chapter.

Barbados

  • Carlisle R. Goddard, MD, FACP - St. Peter

Brazil

  • Andre V. Lomar, MD, FACP - Sao Paulo

  • Cesar Alfredo Pusch Kubiak, MD, FACP - Curitiba
  • Leao Zagury, MD, FACP - Rio de Janeiro

Canada

  • Gary A. Costain, MD, FACP - Saint John, NB

China

  • Tak Hin Chan, MD, FACP - Hong Kong

  • Youming Li - Zhejiang

Colombia

  • Antonio Rafael De Castro, MD, FACP - Medellin

  • Diego Leon Severiche, MD, FACP - Bogota

Indonesia

  • Ari F. Syam, MD, FACP - Jakarta

Japan

  • Masato Kanazawa, MD, FACP - Niigata
  • Yuko Morishima, MD, FACP - Tsukuba, Ibaraki
  • Ayumu Nakashima, MD, FACP - Hiroshima
  • Masahiro Sato, MD, FACP - Kumamoto

Mexico

  • David Gonzalez Kladiano, MD, FACP - Mexico DF

The Netherlands

  • Johannes Berg, MD, FACP - The Hague

Oman

  • Jawaher M. Al-Yazeedi, MD, FACP - Buraimi

Pakistan

  • Muhammad Q. Masood, MD, FACP - Karachi

Philippines

  • Jaime C. Montoya, MD, FACP - Pamploma

  • Eugenio Jose F. Ramos, MD, FACP - Metro Manila

Saudi Arabia

  • Mohammed O. Al Ghobain, MD, FACP - Riyadh

Taiwan

  • Pei-Ming Yang, MD, FACP - Taipei

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New International Members

Welcome New Members!

Welcome and congratulations to the following new ACP Members who were elected from April 1 - May 31, 2011.

Australia

  • Elias H. Nasser, MD - Wollongong NSW

Belgium

  • Gaetan A. de Saint Hubert, MD - Amel

Canada

  • Abdelgalel G. Abdelgader, MBChB - Windsor
  • Zeeshan Aslam, MD, FCCP - Fredericton
  • John S. Bradley, MD - Edmonton
  • Obaid-Ur-Rahman Khan, MBBS - Kelowna
  • Mohamed Lotfy Metawee, MBBCH - North York
  • Dharmapaul Lakshmana Raju, MD, FRCPC - Ottawa
  • Belluru S. Satyanarayana, MD - Bathurst
  • Ashdin Tavaria, MD - White Rock
  • Jennifer Mary Wilson, MD - Vancouver

Chile

  • Gonzalo Alarcon, MD - Santiago
  • Daniela Beltran Farto, MD - Santiago
  • Luisa Duran, MD - Santiago
  • Jorge Perez, MD - Santiago

Dominican Republic

  • Luis Antonio Valerio, MD - Santiago

India

  • Madhu KG, MD - Kerala

Iraq

  • Atheer S. Abdullah, MBChB - Baghdad
  • Ahmed S. Noori, MBChB - Baghdad
  • Frankleen Z. Oraha, MBChB - Arbil

Ireland

  • Mohammad I. Syed, MD - Waterford

Japan

  • Hidehito Horinouchi, MD - Tokyo
  • Takeshi Ishida, MD - Tokyo
  • Hiroshi Ono, MD - Tokyo
  • Kayo Ota, MD - Sakai, Osaka
  • Hiroshi Saito, MD - Tokyo
  • Jun Suzuki, MD - Matsumoto, Nagano
  • Koichi Tamita, MD - Nishinomiya

Myanmar

  • Aung Cho Myint, MBBS - Kamayut, Yangon

Pakistan

  • Sajjad Ali, MBBS - Karachi Sindh
  • Nanik Ram, MBBS - Civil Line Karachi

Panama

  • Eholo Castro, MD - Capira

Saudi Arabia

  • Bader A Alahmari, MD - Riyadh

Sri Lanka

  • Thilak Jayalath, MBBS, MD, FRCP - Kandy
  • Kanapathipillai Thirumavalavan, MD - Colombo

United Arab Emirates

  • Abdulhusain O. Mousa, MBChB - Sharjah


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Highlights from ACP Internist and
ACP Hospitalist

ACP Internist (formerly ACP Observer) May/June 2011

  • Food allergies are a tough nut to crack
    As public awareness of food allergies increases, identification and management into adulthood can be difficult to sort out, carrying the risk of misdiagnosis, according to specialists who are trying to improve physician education.
  • Internists don't need to defer treating pain
    Pain is one of the most common symptoms seen by primary care physicians, but it can be the most difficult to handle. Chronic pain often requires time-intensive, complex regimens that call for careful management and monitoring, which is not easy to achieve in a busy primary care practice.
  • Experts offer advice on oral drugs, insulin for diabetes
    Any type 2 diabetic is eventually going to need oral medications, and some on oral medications may eventually progress to needing insulin. The regimens are complex and vary from patient to patient. Learn how to individually tailor such decisions.
  • Manage diagnosis, follow-up of depression systematically
    Improvements to treating depressive symptoms led to improvements in A1c levels and blood pressure in one internist’s practice. A systematic, manageable approach exists to diagnosis and treatment.

ACP Hospitalist May 2011

  • You can reduce antibiotic resistance
    Leading an antibiotic stewardship program is within the reach of hospitalists at even the smallest community hospitals.
  • Pocket-sized procedures
    Ultrasound images, formerly only available from machines weighing hundreds of pounds and costing hundreds of thousands of dollars, can now be viewed on devices significantly smaller in both size and price.
  • Discussing prognosis
    Physicians not only overestimate prognosis, many consciously present a more optimistic prognosis to patients than they privately believe.

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    College Corner

    Global health course featuring ACP leadership and policy in Italy this summer

    ACP members are invited to participate in the European Genetics Foundation's (EGF) summer course in Comparative Health: The Reforms of the Health Care Systems in a Globalized World, co-directed by ACP's associate executive vice president John Tooker, MD, MBA, MACP, and featuring an array of international speakers.

    This post-graduate level course will be held Aug. 29 to Sept. 2, 2011 at the Euro Mediterranean University Center of Ronzano in Bologna, Italy, and will provide an up-to-date review of the field of comparative studies of health systems and medical care. ACP and its health care reform policies will be included in the course. More information and registration for the course are online.

    Reader Submissions

    ACP International welcomes submissions from its readers. If you would like to submit an article for consideration for the newsletter, please send it to the ACP International Office mailbox. Articles submitted for consideration should be formatted in a Microsoft Word document and no longer than one page of 12-point Times New Roman font. Articles about unique health issues routinely treated in your country and humanitarian stories are encouraged.

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    MKSAP 15 Answer & Critique

    Answer: C, Chronic vasomotor rhinitis.

    Educational Objective: Diagnose vasomotor (nonallergic) rhinitis.

    Critique: This patient has chronic vasomotor (nonallergic) rhinitis, which is caused by increased sensitivity to irritants in the air. The pathophysiology of vasomotor rhinitis is less clear than that of allergic rhinitis, but the chemical mediators causing symptoms are similar in both conditions. Symptoms of vasomotor rhinitis include nasal congestion and rhinorrhea and may develop after exposure to odors, humidity, temperature change, and alcohol. Sneezing and itching occur less often than in allergic rhinitis. Some experts consider the diagnosis one of exclusion. Results of skin tests and radioallergosorbent tests are normal in patients with vasomotor rhinitis and can be used to differentiate this condition from allergic rhinitis. Some patients have both allergic and nonallergic rhinitis. Chronic nonallergic rhinitis is less responsive to therapy than is allergic rhinitis. Topical intranasal corticosteroids, topical intranasal antihistamine, and topical ipratropium are the most consistently effective treatments.

    Allergic rhinitis is unlikely in this patient because his symptoms are increased by humidity and pollutants, and there is no seasonal variation in symptoms, no family history of allergies, and no constitutional symptoms associated with allergic rhinitis. In addition, most patients develop allergic rhinitis before 20 years of age.

    Chronic sinusitis is unlikely in this patient because of the absence of mucopurulent nasal drainage, facial pain or pressure, or decreased sense of smell.

    Rhinitis medicamentosa refers to the syndrome of rebound nasal congestion after discontinuing topical a-adrenergic decongestant sprays. Symptoms may occur after using these sprays for 5 or more days and resolve with prolonged discontinuation of these agents. However, this patient has not used nasal sprays. Rhinitis may be induced by other drugs, as well. Medications generally associated with drug-induced rhinitis include aspirin, NSAIDs, oral contraceptive agents, angiotensin-converting enzyme inhibitors, prazosin, methyldopa, ß-blockers, and chlorpromazine.

    Key Point: Chronic vasomotor (nonallergic) rhinitis should be considered in patients who develop perennial nasal congestion and rhinorrhea after 20 years of age, whose symptoms are exacerbated by irritant rather than allergic triggers, and who do not have a family history of allergies.

    Bibliography

    Quillen DM, Feller DB. Diagnosing rhinitis: allergic vs. nonallergic. Am Fam Physician. 2006;73(9):1583-1590. [PMID:16719251] - See PubMed

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MKSAP 16 Holiday Special: Save 10%

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Maintenance of Certification:

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Maintenance of Certification: What if I Still Don't Know Where to Start?

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