"Doctors have lost control of medicine, which has passed to the bureaucrats"

Of Carlos Lezcano
Special for El Litoral

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

– When and how do you travel to the United States?
– I was finishing medicine, I already knew a lot of English and I was studying German because I had the chance to go to Germany, the Netherlands or the United States to specialize.
To go to Germany and the Netherlands I had to get a scholarship and the European scholarships paid me very little. I was already married, my wife was pregnant, the payment was minimal and especially with those scholarships you can not work outside the university.
In the United States, the system was different. You had a job as a resident in a hospital and they paid me a good salary, which was three or four times higher than what I was paying in Europe.
At that time there was also a sad phenomenon in the United States. They were in the middle of the Vietnam War and many young doctors were sent there, and in the United States hospitals needed more young doctors for hospital residences. That situation helped me a lot. I took the exams necessary to re-validate my degree in the United States, which was a tremendous effort. It was a three-day exam, in which you were asked questions about everything related to medicine, from the first to the last year. And of course, in addition, all in English.
As I was preparing for the exam, I had already sent an application with all my data to about 60 hospitals in the United States. After the test, we had to wait about three months for the results to arrive by mail. He was there, waiting for the letter with the results, when one afternoon the phone rang at home. They were calling me from a Philadelphia hospital. "Look, we offer you a residence, we'll give you a furnished apartment and we'll pay you $ 900 a month." Then, through a series of coincidences and great luck, I was able to continue my training at the hospital of my dreams in Boston, because it is associated with the Harvard Medical School and the best diabetes clinic in the world. It's called Joslin Clinic, which has a part of medical care and a whole part of the research just for diabetes.
– What's c & # 39; is and that there is no other place?
– A high level of research and they also have the part of medical assistance that is also excellent. I have seen patients from all over the United States and all over the world, with all the problems and different types of diabetes. I started working in the part of the hospital, called New England Deaconess. The Joslin clinic has only clinics, has no hospitalization.
– How is it done in that system to study and work?
– It is relatively simple. You work a lot and study a lot. When I arrived in Boston, I understood immediately – it was very easy! – that the level of the other residents of my year was very high, well above mine. All of them were "titans of medicine". In the clinical meetings ("business lunches") we had each morning, I saw how they managed the science of medicine, the diagnoses and the therapies with so much knowledge and experience. This forced me to study, study and study.
– And when did the time come to teach?
– In university hospitals in the United States, clinical work is completely integrated with education. The first day I started at the Boston hospital, I was assigned a patient apartment, two first-year residents and two or three medical students to work, monitor, and teach. So I had to manage a team of about 5 or 6 people where we treated hospitalized patients with very serious problems and at the same time I had to teach them. This was during all my time as a medical resident. Later, when I was already a resident endocrinologist at the Joslin Clinic, I had to do a lot more teaching, especially the year I was a head resident there. He did much more than teach, had to organize all the conferences of the week, which were many, he organized the interaction of the clinical part with the "titans of research" who do not see patients and have a more scientific view of the problems . Over the disease, researchers see molecules and mechanisms, trying to improve our knowledge. This has created many discussions, very important, almost daily, in which we have all learned.
This is why I had less "wellness" work. I did an outpatient clinic, alone or with the youngest, three afternoons a week, nothing more. The rest of the time I had a free letter to devote myself to education, several weekly conferences that I had to organize, find interesting cases to discuss, get speakers for each topic not only inside the clinic but from other parts of the states United … or from the world sometimes.
– Why do you think other residents were better?
"Because almost all Americans were trained in the best medical schools in the United States, not just at Harvard, we had Columbia, Yale, Hopkins, Stanford, and other high school graduates. Other than that, they were very intelligent and dedicated. But one day came when I began to feel a little better. One weekend I was on duty at the hospital and was admitted to a patient with very rare diabetes, with rare complications that did not seem diabetic, responsible for one of the best residents, David. He was one of my most envied idols, not only because he was very intelligent and knew a lot, but moreover he was a good man and a great friend. I hear the buzzer, I answer by phone, it was David telling me "Arturo, I'm admitting a patient with very strange problems, would you do me the great favor of coming to see him and help me?" Initially I thought it would be even a joke … but David was so "perfect" that he did not make jokes. More scared than interested, I went to see the patient. First of all, David presents the entire clinical history and then we examine it together. I immediately noticed several anomalies that the patient had, which were not necessarily caused by diabetes and I remembered something I had studied about it. I said: "It seems to me that this patient has a very rare diabetes due to an excess of iron accumulation in the body". I thought it was a rare hereditary disease called hemochromatosis. It was the coincidence that I had read a lot about this disease because I was interested in the rare and its relationship with iron metabolism. I had never seen a case of those before, but … I remembered that they have a severe form of arthritis, they have a hardening of the liver and atrophy of the testicles. The most obvious clinical feature is that the skin darkens, as if they were "toasted". In the past they called it "tanned diabetes" for this reason. That same night we ordered all the necessary analyzes, which confirmed the diagnosis and the day after we presented to the rest of the residents together with David. Presenting an "au pair" case with David was the glory for me. From that moment on, my status has changed, not only with the other residents but inside me. I began to feel that I was "coming", that I was not so inferior to others.
– Has the particular relationship you have with your patients changed?
-It has changed a lot, medicine has changed a lot. First of all, we lost a great sense of science and the academic world, medicine has become more of a business. Unfortunately, doctors have lost control of the medicine that has passed to the bureaucrats, people who only understand business and money. Medicine managed only by doctors can become more expensive, but medicine in the hands of bureaucrats becomes very impersonal, where health and pain are much less important than weights and cents. We doctors have become health system employees all over the world, and every day with more bureaucracy and bureaucracy, even if typed. This means that we have less time to know and understand the patient, at the same time that we increase the economic interests of seeing more and more patients every day to survive. The financial bureaucracy of health has surpassed the effectiveness and has distorted the fundamental interests of medicine. And I say medicine instead of doctors, because hospitals and clinics are managed in the same way. Cost of effectiveness, without taking into account the needs of patients. We doctors are becoming less efficient in all the bureaucracy of public and private health systems. It is a struggle between cost control and the ability to offer patients the best and most recent science. I must confess that, at least in part, it is also the fault of science.
– What is health insurance in these cases?
– Health insurance obliges us to act in ways other than what our experience tells us and we are forced to navigate between these multiple and blocking interferences. The treatment to be given is not what we consider the best, but insurance allows us. Medicine must be a direct relationship between doctor and patient, but this unyielding, parsimonious and insensitive intermediary, which is the health system, has been added to it. A wedge was created between the patient and the physician, starting with growing bureaucracy for both patients and physicians. The imposition of economic decisions has been created on scientific ones.
– It means a lot of time. Sometimes time is urgent.
"Time is money, the English say – in our case, the time of every consultation is very important, but now we have to use it more for compulsory paperwork than to talk and try to get to know the patient. without knowing him, without understanding his personality, his way of being, his life, his family, his environment, medicine is not and should not be impersonal, and in patients with chronic diseases such as those treated, diabetes, hypertension, cholesterol, obesity, etc. At this time it is impossible for us to have enough time for this.In addition, the universal use of computers instead of having lightened the bureaucracy, has increased it to doctors.
-In your specialty, which is the endocrinology, what are the main problems at the moment?
– Inside of what is endocrinology we have two main areas: the first, which is the largest, 70% of our work is diabetes. "A sweet disease but with bitter complications". Diabetes is a problem that is growing exponentially all over the world, which presents us with very big challenges that we have not yet solved. The researchers who discovered insulin in Toronto – Canada left part of the money they won with the Nobel Prize to put in the Canadian Diabetes Association two votive lamps that are always on and off only the day we take care of diabetes. Day after day, month after month, I'm still up …
The science of diabetes has advanced a lot, especially in the last five or ten years. But the root of the problem of type 2 diabetes or of the adult, the most frequent, is obesity. The increase in global obesity due to the effect of the food industry has greatly increased the prevalence of this form of diabetes due to obesity and continues to grow. I had the opportunity to go to Asia many times and in relatively poor countries like India, China, Pakistan and others, obesity has increased and continues to increase due to the constant temptation of # 39; food industry, which offers very appetizing and advertised foods, at a very low price, step or with "delivery". Obesity does not yet have an effective, safe and permanent treatment, despite all the newscasts, publications and the Internet. If we could cure or prevent obesity, we would eliminate most type 2 diabetes. The increase in diabetes in the third world presents an even more serious health problem. Junk food is relatively cheap, which puts obesity "within everyone's reach". On the other hand, the treatment of diabetes and its complications (heart, kidney, blindness, amputation) is very expensive and many of these countries do not have the economic means to deal with them. It is economical to become obese and have diabetes, but it is expensive to treat them.
The second part of the relatively common endocrinology, 30 percent of our work, is with the thyroid gland, which is also common but much easier to treat. For the reduction of thyroid function or hypothyroidism, treatment is the simplest and most effective in all medicines: a pill that is taken every day, economically and without collateral phenomena.
We are diagnosing thyroid tumors long before and it is very rare for someone to die of thyroid cancer with the treatments we have now. Even the overactive thyroid or hyperthyroidism are very easy to treat. The other problems of endocrinology, adrenal glands, pituitary glands, testes, parathyroids, etc. They are much less common.
– On the one hand, research, but on the other, there are the cultural themes of habits. It's right?
-Yes and the research does not cure the problems caused by the habits of human nature. This is the problem that leads me to say sometimes "education will not reduce obesity". We all know what we have to eat but we do not. Eating is a pleasure that exceeds intelligence and will. Undoubtedly there is a genetic tendency to obesity, but the most important factor is the increase in diet, a non-hereditary, acquired factor of "modern life" that has increased obesity and type 2 diabetes.
-In India, in China … in India they are mostly vegans, vegetarians.
-The fact of being vegetarian does not mean that they are not obese. I always remind you that elephants are vegetarians. So, people who say "I'll become vegetarian or vegan to lose weight" should remember that it's not necessarily what happens.
-What was the main reason to study?
-In essence, the central problems have always been obesity and diabetes. But I'm also interested in a congenital alteration of the testes, called XXY or Klinefelter syndrome. I am still studying a disease of women that has become much more common and the most common cause of infertility, the polycystic ovaries. Increased calcium in the blood and, as I said before, hemochromatosis.
In recent years I have also dedicated myself to something that is closely related to obesity, which is the sense of taste. I am convinced that the sense of taste through its "pleasure and wellness" effects at the level of the brain has much to do with the fact that we eat more than necessary. It is not a meal for caloric needs, it is a eating for the pleasant effect that calories produce in the brain and that we gradually understand more. I have prepared a series of conferences to try to explain obesity with an increase in what we eat for pleasure, what I call "emotional appetite".
-How does taste and satiety work?
-The sensations of taste and satiety are united in two interconnected centers in the center of the brain, in an area called the hypothalamus. We have come a long way in recent years to understand how these two centers work through chemicals called neurotransmitters. One of the most important is the "Fattore Agouti", initially discovered in the determination of the mantle of a Latin American rodent that actually has a name Guarani, Acutí.
Appetite and satiety …
-The problem that humans have is that we have been programmed to tolerate food shortages very well. Immediately when we do not have enough food and we start to lose weight, a very intense feeling of hunger appears, which leads us to eat and prevents us from losing weight. On the other hand, we do not have overweight protection, we start to gain weight slowly, without realizing it. Most obese people do not realize initially that they are becoming obese for a long time. Once obesity is established, it is very difficult to stop it and lose weight.
– And how do you see the operations related to obesity?
-We must do it by force in very obese people because we do not have effective and safe medical treatments. Our Boston hospital was one of the pioneers in doing these operations that are now called "bariatric" and that have already been done all over the world. When we started we had many surgical and metabolic problems, but now it can be done with minimal risk in expert centers that are committed to following patients for the rest of their lives. After the initial benefits of these "gastric bypasses", metabolic problems appear that must be prevented and / or treated. The main one is that after about 5 years many of the patients start to gain weight. It is an organic and psychological mixture.

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