Dr. David Kershenobich Stalnikowitz
Director General
Salvador Zubirán National Institute Medical Science and Nutrition (INCMNSZ)
View from the Top

Groundbreaking Models for Internal Medicine

Sat, 09/05/2015 - 13:57

Q: What have been the latest developments and achievements of INCMNSZ?

A: The INCMNSZ was created to address nutrition and internal medicine, focusing on all aspects of the internal medicine for adults but traumatology and gynecology. Ours is a third-level hospital with advanced equipment and trained personnel capable of handling highly complex situations. We have expanded the ER from 400m to 1,600m. A common problem up to this point was that patients waiting for emergency consultations were in the same room as hospitalized patients in semi-critical condition. We have also improved our methodology to treat ER patients by providing manuals detailing the process to triage patients which used to take up to five hours. This handbook has speeded up the admission process to three minutes after the patient arrives. We have also upgraded the emergency area included a simple tomography, dialysis equipment, and procedural rooms to provide fast attention for emergencies. We receive more than 100 emergency patients on a daily basis with complex cases that have not found resolution in other hospitals. We have also worked for the past two years in creating our own electronic system, which will link all our services and will be portable to allow doctors to provide consultations outside the institute.

Q: The institute is responsible for several nutrition programs, including “Un kilo de ayuda” (A Kilogram of Help). What impact have these programs had?

A: The institute was founded when malnutrition was a large problem in Mexico. Nowadays, the percentage of the population facing this problem has greatly reduced, but it is still an important matter for the country. At present, we face the opposite problem: obesity and its consequences, an issue that is threatening a large, growing percentage of the Mexican population. Two very different sets of knowledge are required to tackle both segments of the spectrum. To handle undernourishment, we run several programs including “Un kilo de ayuda,” which is focused on supporting nutritional development by providing nutritious food to the most marginalized areas of the country. We are also present in many indigenous communities in Oaxaca and in Tarahumaran, in order to educate the populations on nutrition and train medical personnel to be able to handle nutritional needs. The INCMNSZ currently supports other institutions such as the Ministry of Social Development (SEDESOL) and the Government of Mexico City in specific programs such as SaludArte. Also, we publish the Nutrition Notebook (Cuaderno de Nutrición) addressed to all the population to instruct them on health improvement. Our tactic against obesity is to focus on nutrigenomics, and we stand as the forefront of this area worldwide. The INCMNSZ is currently researching endemic food to understand how they affect the genes of the population, and to determine their role in the obesity crisis.

Q: What is the institute’s research focus at the moment?

A: In the area of nutrition we have an important research project on gut microbiota, which will have a considerable impact on the Mexican population. There are more genes within our gut flora than in our own genes, so our goal is to map their interaction. It is a popular opinion among researchers that the genes of our gut flora are strongly related to the development of several diseases, including chronic ones. We also have research lines in internal medicine mainly in obesity and diabetes.

The institute is collaborating with the Broad Institute of MIT and Harvard in Boston, to map polymorphisms in diabetics. We determined that some polymorphisms increase the possibility of developing diabetes mellitus by a multiple of six. A third area is related to infectious diseases, inculding HIV and tuberculosis, for which we have biosafety level 2 and 3 (BSL 2 and 3) laboratories One of our latest accomplishments is our Research Support Network (Red de Apoyo a la Investigación), launched in January this year alongside the National Autonomous University of Mexico (UNAM), the National Institute of Oncology (INCAN), the National Institute of Cardiology (INC), and the National Institute of Genomic Medicine (INMEGEN). The network allowed us to repatriate 15 Mexican researchers that were living abroad, and required the creation of a core laboratory within our institute to provide assistance to researchers in several areas.

Q: An important problem in Mexico is the lack of specialized physicians, especially in rural areas. What is the institute doing to address this situation?

A: I believe that the problem is the lack of general practitioners. With the current telecommunication systems, including television, internet, and cellphones, it is not necessary to have specialists all over the country as consultations can be provided by general physicians who may request specific information from remote specialists. The institute integrates several telemedicine classrooms to provide remote consultations and conferences. The main thing to focus on is educating the general population and providing them the way to change their habits and prevent diseases. Educating physicians on the available resources and the best way to use them is a crucial element of our work. Because nutrition is a complex issue, it requires long and sophisticated solutions, not just more specialists.

Q: What are the profiles of your university collaborators and your students?

A: We are collaborating mainly with UNAM, since our residents are incorporated to UNAM’s training programs. For undergraduate studies, we are collaborating with the Panamerican University, La Salle University, Anahuac University, Tecnológico de Monterrey, and the Autonomous University of Nuevo Leon (UANL), among many others. Through the years, the institute has searched for the best ways to select its residents. Now, just to be eligible for our admission tests, a student’s grades have to be within the top 10% of his or her university. Every year, we receive about 500 requests that comply with this requirement. All undergo a written examination and personal interviews with several members of the institution. From this demographic, we select a total of 160 residents. We focus on selecting committed and involved doctors interested in teaching and doing research. This allows us to select the best students to improve our human resources.

Q: Besides education and innovation, on what other areas do you focus to improve public healthcare in Mexico?

A: Our responsibility as an institute is to develop healthcare models that can be incorporated into the health system. For example, chronic non-transmittable diseases such as diabetes mellitus, hypertension, and chronic renal damage cannot be cured, only managed. As such, they require attention not just from one doctor or specialist but from several over the patient’s entire life. The previous system required a patient to have frequent 15-30 minute consultations with several specialists over the course of various days, and our new model provides integral care where patients receive several consultations one day over the course of six hours. After four monthly medical visits, the patient is fully aware of his or her disease, and prepared to manage it without constant sessions. Further consultations, are only required once a year. This model has been highly successful and it has even been incorporated to other hospitals. There is a similar need to change these models for other diseases, such as leukemia and lymphoma. While the INCAN is responsible for dealing with these diseases, our responsibility is creating novel models of care.

Q: How do you approach research and innovation within the institute?

A: Medicine requires the cooperation of all the national and international institutions to keep up with the latest developments in research and education in order to provide the best care to patients. In September, we will have a training program for doctors so they can update their knowledge on internal medicine. For example, in the area of Hepatitis C we are working with the newest direct antiviral agents that are able to cure the disease instead of just managing it. In this case, we are bringing a researcher who developed one of these medications. In the area of anesthesia, there is a new concept called pain- out, which mitigates post-surgery pain, for which we are also bringing researchers involved in the development of this new technique. For this program, we always identify 15 global leaders in their respective fields to share their knowledge on generating new ideas. We also plan to continue with the Cathedra Salvador Zubirán, which aims to bring to Mexico foreign researchers interested in working and living here for a year.