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November 2011


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Internal Medicine: Global Perspective

Antonio Carlos Lopes, MD, FACP
President, Brazilian Society of Internal Medicine

Brazil is the giant of South America with nearly half of the continent's area and people; worldwide it ranks fifth in both area and population, which is as diverse as it is large. About 54 percent (103 million) are mainly of European origin, descendants of immigrants from Portugal, Italy, Spain, Germany and Eastern Europe. Political progress continues after years of military dictatorship gave way to civilian rule in 1985. Recent censuses reveal social progress, with lower infant mortality rates and higher literacy rates. São Paulo, with some 10.9 million people, is Brazil's largest city—and one of the world's largest metropolises. It is the leading industrial producer and financial center. The Southeast region of Brazil includes São Paulo, Belo Horizonte, and Rio de Janeiro—the economic hub of Brazil, containing more than 40 percent of the country's population
-source: National Geographic

What inspired you to become a physician?

I always wanted to be a physician since I was a child. My aunt, who was an obstetrics nurse, helped my mother to raise me and had a great influence on my career choice. I believe that my aunt inspired me to become a physician.

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

In an ideal health care system, the internist should be the first physician to come in contact with the patient. When patients seek care from an internist, they expect their physician to spend time with them, to answer their questions and perform a clinical exam in order to perform an accurate diagnosis.

In my opinion, internal medicine is extremely important, because a well-trained internist is able to solve 70 percent of the population’s problems at very low cost to the community. However, our society values the doctors who demand many subsidiary exams without examining the patient. This is, in part, responsible for a very expansive and unaffordable health care system in Brazil.

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

There are many challenges facing internists in Brazil. We must provide better salaries to those doctors who work both in public and private health care systems. It is also imperative to prevent the indiscriminate opening of new medical schools, Brazil has many low-quality medical schools that do not offer students the highest standard of medical education. Medical students graduating from low-quality medical schools is an important part of the problem that leads to second class physicians and therefore, affects the quality of care available to patients.

Brazil has a large number of medical schools. Our country has more medical schools than China, which has over 1.3 billion people, and 150 medical schools and the United States with more than 300 million people and 131 medical schools. Recently, the Brazilian Ministry of Education started to tighten the restrictions around the operation of low-quality medical schools. This was a very critical measure, but still is insufficient in solving the entire problem.

Even if the Brazilian Ministry of Education reduced the number of spots available to students in low-quality medical schools from 100 to 50, it would still mean that they would be agreeing with providing low-quality training for medical students. This would mean allowing at least 50 medical student graduates trained in low-quality medical schools to practice medicine without the appropriate training. Our suggestion is to immediate close all low-quality medical schools in the country. Students attending those schools should be transferred to other schools that offer better conditions for higher quality training and education.

What are the most common chronic illness and how they affect the day-by-day job of an internist?

The chronic illnesses that are most common in Brazil are the osteoarticular diseases such as hypertension, obesity, diabetes and chronic obstructive pulmonary disease. I always try to reinforce the notion that the internist is a specialist who is well prepared to determine the accurate diagnosis and subsequent treatment of all of the above mentioned diseases.

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

Internal medicine is the oldest of all medicine specialties and also the broadest and most extensive. It was through this specialty that our profession began, but over the years internal medicine has lost ground to the other specialties. There is no doubt that the excess of medical specialists from other areas in relation to the number of internists (mainly in major cities), has contributed to the problems in medical assistance, both individual and collective, ambulatory, and in the hospitals. It is clear that those well-educated internists also have the ability to solve the vast majority of the clinical diseases with humanity, sensibility and at a low-cost. For specific areas, specialists are helpful and will solve the complicated cases.

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

Those kinds of debates are always highlighted in the media, because the health care provided to the Brazilian population is not of the highest quality. We mostly suffer from lack of investment in the health care industry. A report from the World Health Organization (WHO) indicates that despite possessing what is in theory a pioneering health care system model, the health care system works very differently in practice. Among the 192 counties evaluated, Brazil ranks 151st. To put the situation into perspective, the portion of the country’s budget that is allocated to health care spending is only six percent. In comparison, the average African country, even the countries with extremely poor regions and numerous social problems, spent on average 9.6 percent of their national budget on health care. Therefore, we cannot begin to discuss the creation of specialized services without first making the current health care system efficient. The largest investment should be in primary care, which treats around 70 percent of the population’s illnesses at a low cost. This demonstrates the discrepancy between those who advocated for the current health care system and those who actually practice medicine within Brazil’s health care system.

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

It is very difficult to evaluate the quality of health care systems around the world, considering that each of those systems was created to meet each country’s needs and cultural requirements. From my perspective, all countries must have a high quality health care system focused on providing care for patients from lower economic backgrounds who cannot afford private health care assistance.

What could other countries learn from the health system in Brazil?

The health care system in Brazil is considered by all health workers of the world as one of the classic model of universal health care assistance. However, up to now, the system is not as good in reality as it was when it was first conceived because it suffers from lack of resources. Without the approval of an amendment in the Federal Constitution, which will establish the minimum investments in health care system, our health system will not survive.

Is access to electronic information and products influencing what patients want from their doctors in Brazil?

In a world where the information is widely available, especially through the internet, a new phenomenon was created that I usually call "Dr. Google”. Thanks to such tool, the patient is more informed about diseases and therapies. However, it also increased the risk of indiscriminate use of drugs and self-diagnosis. It is a two-way street that can be very dangerous. We must not forget that the doctor is the only one who has the responsibility and the one well trained to perform the diagnosis and propose the most appropriate treatment.

What are your responsibilities as President of the Brazilian Society of Internal Medicine?

The goal of the Foundation of the Brazilian Society of Internal Medicine is to bring together physicians who are engaged in internal medicine, to promote courses and conferences, to update and disseminate knowledge in several areas, to evaluate physicians and provide board certification in internal medicine.This work takes place through four pillars: the development of physician-patient relationship, the humanization of medicine, the democratization of knowledge and to perform equal opportunity assistance to everyone, without distinction of race and social classes.

What you would like to accomplish/contribute during your tenure as President of the Brazilian Society of Internal Medicine?

I was one of the co-founders of the Brazilian Society of Internal Medicine and, in order to get where we are today, we have had quite a few struggles. Currently, the society has 18 chapters all over the country and more than thirteen thousand members, which demonstrates that our work has taken the right direction. We hope to further enhance internal medicine by reinforcing the humanistic characteristics of the field, and focusing on the patient, which inevitably implies a critical discussion about the quality of medical training.

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

My biggest challenge as President of the Brazilian Society of Internal Medicine was to enhance the knowledge of physicians, especially in the most remote areas of the country. The greatest reward I had was to have redeemed the humanism in medical practice and to have improved the physician-patient relationship throughout the country, influencing other medical specialists as well. I always try to show that the advancement of technology cannot replace the doctor's relationship with his or her patient.

Does the Brazilian Society of Internal Medicine have collaborative relationships with other societies and if so, is it beneficial to your society now?

The Brazilian Society of Internal Medicine was founded twenty years ago and we are thankful for the support of our collaborators who have worked with us. We are also grateful to key associations such as The Regional Council of Medicine, The Federal Council of Medicine and The Brazilian Medical Association, which all have always given us all of their support and legitimacy to the work of our society.

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Update Your Knowledge with MKSAP 15 Q & A

A 68-year-old man comes for a routine evaluation. He has a 20-year history of difficult-to-treat hypertension. He has gained over 9.1 kg (20 lb) in the last 15 years. He does not smoke cigarettes and consumes less than 2 oz of alcohol daily and less than 8 oz weekly. He tries to walk 6 blocks every day. Medications are lisinopril, 20 mg/d; amlodipine, 10 mg/d; and hydrochlorothiazide, 25 mg/d. He adheres to his medication regimen and takes no over-the-counter medications.

On physical examination, blood pressure is 160/95 mm Hg. BMI is 32. He has generalized obesity without skin changes. There is generalized abdominal obesity but no tenderness or organomegaly. The remainder of the examination is normal.

Laboratory studies reveal normal serum electrolyte, blood urea nitrogen, and serum creatinine levels and a urine albumin-creatinine ratio of 50 mg/g. A work-up for secondary hypertension is negative.

Therapeutic lifestyle changes are reinforced.

Which of the following is the most appropriate next step in this patient’s management?

A. Atenolol
B. Clonidine
C. Doxazosin
D. Spironolactone

Click here for the answer and critique.

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Internal Medicine 2012 - New Orleans, Louisiana
April 19-21, 2012

Internal Medicine 2012 Welcomes International Attendees

Click here for more information.

Join us for these international activities at Internal Medicine 2012
International Reception

Thursday, April 19, 2012
8:00 - 9:30 p.m.
HQ, Salons A-E

This reception is open to all international attendees and their guests, as well as other attendees who are interested in meeting with leaders from ACP and internal medicine societies from around the world. Light hors d' oeuvres will be served.

International Courses
Amerindian Contributions to Modern Medicine - MTP 109

Saturday, April 21, 2012
8:15-9:15 a.m.

Faculty: Jorge Hidalgo, MD, FACP, FCCM, FCCP

This Meet the Professor course will discuss the historical contributions of ancient Amerindian medicine to modern medicine. It will combine not only history, much of which is little known to many physicians, as well as fascinating medical/historical facts.

This workshop is the fourth in a planned multi-year series presented under the sponsorship of the International Council, on "Contributions of Multiple Global Cultures to Modern Medicine".

Challenges to Professionalism in 2012 - PN 020

Friday, April 20, 2012
11:15-12:45 p.m.

Moderator: Jock Murray, MD, MACP
Panelists: Werner O. Bauer, MD, FACP, FRCP
Kesavan Kutty, MD, MACP

This panel of international faculty will address internal and external pressures on professionalism that pose challenges to the practicing physician and discuss strategies to maintain professionalism in the face of challenges.

Hotel Discounts

Book early for the best rates on hotels in New Orleans during Internal Medicine 2012. Great, wallet-friendly hotels for under $200 available to only Internal Medicine 2012 attendees. Click here for a complete list of hotels.

Discounted Registration Rates for International Delegations

Receive a registration discount of up to 20% off the regular member price for groups of 10 or more. The guidelines require that one person organize the group, provide the registration forms, and submit one check for the entire group.

Groups of 10 - 19:

Scientific Program - $495 pp (regular member price is $579-$649)

Pre-Session 1-day Course* - $199 pp

Pre-Session 2-day Course* - $399 pp

Groups of 20 or more:

Scientific Program - $470 pp (regular member price is $579-$649)

Pre-Session 1-day Course* - $179 pp

Pre-Session 2-day Course* - $369 pp

pp = per person fee.
* Does not apply to Pre-course(s) that have a higher fee due to close faculty/student interaction or special equipment.

Please submit completed registrations by January 28, 2012.
Submit to:
Pamela Carey
Senior Associate, Customer Service
190 N. Independence Mall West
Philadelphia, PA 19106

For further information contact Pamela Carey at +1-215-351-2792 or pcarey@acponline.org.

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International Meetings Update

10th Congress of the European Federation of Internal Medicine Meeting
October 5-8, 2011

The European Federation of Internal Medicine (EFIM) held its 10th Congress from October 5-8, 2011 in Athens, Greece. The meeting was held jointly with the 17th Congress of the Hellenic Society of Internal Medicine (HSIM). The meeting was attended by approximately 1,000 individuals from all over the world, though most were from Europe. There were students and residents as well as physicians in attendance.

Virginia Hood, MBBS, MPH, FACP, President of the American College of Physicians, was invited to attend as the ACP International Ambassador by the Scientific Committee Chairs of the meeting, Professor Ramon Pujol Farriols, MD, EFIM President, and Professor Sotirios A. Raptis, MD, PhD, HSIM President. Dr. Hood spoke on the topic of High Value, Cost Conscious Care.

An ACP exhibit booth was also present at the meeting.

From left: Dr. Ramon Pujol Farriols, EFIM President; Jim Ott, ACP SVP for International Programs; Dr. Virginia Hood, ACP President; and Dr. Jan Willem Elte, Secretary-General of EFIM on the far right.








ACP Brazil Chapter Annual Meeting
October 26-27, 2011

The ACP Brazil Chapter held it's annual meeting October 26-27, 2011 in Curitiba, Brazil, in conjunction with the annual meeting of the Brazilian Society of Internal Medicine. There were approximately 4,800 attendees at the meeting. Internal medicine physicians, residents, and medical students from all over Brazil attended.

Virginia Hood, MBBS, MPH, FACP, President of the American College of Physicians, was invited to attend as the ACP Leadership Liaison and Dr. Tanveer Mir, MD, MACP, was the invited ACP International Ambassador to the meeting. They both did a total of six lectures and were invited to tour the medical school and hospitals. They also had the opportunity to interact with a large number of students, faculty, and residents on a daily basis.

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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 Gambia, Mexico, and Taiwan.

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New International Members

Welcome New Members!

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

Argentina

  • Silvia Beatriz Hernandez, MD - Buenos Aires

Australia

  • William L. Browne, MBCHB - Box Hill
  • Ashim K. Sinha, MBBS - Cairns

Barbados

  • Wayne S. Clarke, MD - Saint Philip

Canada

  • Atlal Abu Sanad, MD - Montreal
  • Karima Khamisa, MD - Ottawa
  • Santhosh K. Narayanan Lakshmi, MD - Summerside

Chile

  • Helia Morales, MD - Santiago
  • Jorge Segovia, MD - Santiago

Dominican Republic

  • Gilbert A. Jenouri, MD - Santo Domingo

Egypt

  • Maged Z. Gayid, MBBCh - Aswan

England

  • Hemang J. Dave, MBChB - London
  • Amir Waheed, MBBS - North Lincolnshire

Guyana

  • Chetram Budhu, MD - Georgetown

India

  • Birochan Das, MD - Guwahati, Assam
  • Philip Mathew, MD - Kollam, Kerala

Indonesia

  • Pranoto Budiwidjaja, MD - Surabaya

Japan

  • Noboru Hagino, MD - Ichihara, Chiba
  • Hitoshi Honda, MD - Sapporo, Hokkaido
  • Isao Ito, MD - Sakyo, Kyoto
  • Kenji Kanazawa, MD - Kobe, Hyogo
  • Yasushi Nagaba, MD - Kitamoto Saitama
  • Nobuhiko Nakazato, MD - Naha, Okinawa
  • Takashi Sekikawa, MD - Ehime
  • Naoko Takei, MD - Ichihara, Chiba

Jordan

  • Ghassan I. Kawar, MD - Amman

Lebanon

  • Zeinab A. Issa, MD - Beirut, Hamrah

Nigeria

  • Fatai K. Salawu, MBBS - Yola, Adamawa

Pakistan

  • Tabish Hussain, MD - Islamabad

Panama

  • Lorena Noriega, MD - Panama

Saudi Arabia

  • Mohammed Mahdi Althaf, MD - Riyadh, Ar-Riyadh

United Arab Emirates

  • Janan Q Al-Khayat, MBChB - Abu Dhabi

Uruguy

  • A. Veronica Perez Papadopulos, MD - Montevideo

Venezuela

  • Alonso J. Valladares, MD - Caracas, Miranda

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Highlights from ACP Internist and
ACP Hospitalist

ACP Internist (formerly ACP Observer) September-November 2011

  • Internists healing tsunami's aftereffects
    Six months after an earthquake and tsunami, Japan's populace and its clinicians are sizing up the long-term health effects of the physical injuries, the mental trauma and the damage to the nation's health care facilities. Internists describe the aftermath in their own words.
  • Medical missions in Iraq help train next generation of doctors
    U.S. military physicians are helping to train Iraq's next generation of doctors, as well as helping to restore an infrastructure smashed by decades of neglect, then combat.
  • Sports internists treat players as patients
    These internists turned their own athletic pursuits into careers for professional sports teams, treating high-caliber athletes as they practice and play. When working the sidelines, it's just another day not at the office.
  • HIV comes of age as disease of mid-to-late life
    Protease inhibitors revolutionized management of HIV, morphing it from a death sentence to a chronic, manageable condition. Medical issues have since grown more complex as doctors consider how HIV interacts with aging, and how aging interacts with these sometimes toxic drugs used to control the virus.

ACP Hospitalist September-October 2011


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    College Corner

    ACP launches new online discussion group for hospitalists

    ACP members are invited to participate in ACP's Special Interest Groups, a private online community that allows members to share experiences, questions and creative solutions with like-minded physicians at their own convenience. The special interest group forums are free and exclusive to ACP members. Members can connect with fellow colleagues in hospital medicine to discuss topics such as work schedule, practice type, and inpatient vs. observation status as well as share tips for getting the most out of committee work. Signup is required as space is limited. More information is available online.

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    MKSAP 15 Answer & Critique

    Answer: D, Spironolactone.

    Educational Objective: Treat resistant hypertension.

    Critique: This patient has resistant hypertension, and the most appropriate management is spironolactone. Resistant hypertension is defined as blood pressure that remains above goal despite treatment with the optimal dosage of three antihypertensive agents, including a diuretic. Patient characteristics more likely to be associated with resistant hypertension include older age, BMI above 30, higher baseline blood pressure, diabetes mellitus, and black race. Excessive consumption of dietary salt and alcohol contributes to resistant hypertension. Many patients with resistant hypertension have secondary hypertension caused by primary aldosteronism or renovascular hypertension, and these conditions should be excluded.

    Treatment of resistant hypertension should include appropriate lifestyle modifications, discontinuation of agents that may increase blood pressure such as NSAIDs, and correction of secondary causes of hypertension. Mineralocorticoid receptor antagonists are particularly effective in treating resistant hypertension even in the absence of hyperaldosteronism. The Anglo-Scandinavian Cardiac Outcomes Trial evaluated the efficacy of spironolactone among 1411 participants with an average age of 63 years who received this medication mainly as a fourth-line antihypertensive agent for uncontrolled blood pressure. After 1 year of treatment, blood pressure in these patients decreased by approximately 21.9/9.5 mm Hg.

    The benefit of beta-blockers in older patients remains uncertain. Older patients also are more likely to respond to calcium channel blockers or diuretics. Furthermore, combination therapy with an angiotensin-converting enzyme inhibitor and a beta-blocker may not have an additive antihypertensive effect.

    Clonidine may help to lower blood pressure but is associated with significant side effects such as fatigue, drowsiness, and dry mouth. This agent has not been evaluated as rigorously as spironolactone in patients with resistant hypertension.

    Doxazosin has not been shown to be as effective as other drugs in reducing cardiovascular endpoints. In the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT) study, the doxazosin arm was prematurely terminated because of an increased risk of heart failure compared with chlorthalidone noted during an interim analysis.

    Key Point: Mineralocorticoid receptor antagonists are particularly effective in treating resistant hypertension.

    Bibliography

    Chapman N, Dobson J, Wilson S, et al; Anglo-Scandinavian Cardiac Outcomes Trial Investigators. Effect of spironolactone on blood pressure in subjects with resistant hypertension. Hypertension. 2007;49(4):839-845. [PMID:17309946] - See PubMed

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