CLINICAL MATTERS
The practice of medicine is very different around the world. While there are diseases in common for most countries such as heart attacks, pneumonia, and diabetes, there are some diseases that are more common or even unique to different parts of the world. The kinds of infections in each country can be very different from the others because of climate, genetic factors, and available animal reservoirs. Learning the entire field of infectious diseases entails looking at cases not just from your home country but from other places as well.
Aside from my full-time appointments as professor and director at the National Institutes of Health and the University of the Philippine Manila, I am also an adjunct professor at the University of Pittsburgh. As someone who trained in the United States and ended up practicing in the Philippines, this arrangement allows me to take advantage of the best of both worlds. The University of Pittsburgh is one of the top universities in the world and is especially renowned for transplant medicine. Dr. Thomas Starzl, a surgeon who is considered the father of organ transplantation, spent most of his time there and revolutionized the field. Its medical school and public health programs are well-regarded globally and have produced many breakthroughs including the original polio vaccine of Dr. Jonas Salk.
I was invited to be adjunct faculty at the University of Pittsburgh (Pitt for short) because they were interested in having their trainees and faculty rotate through the Philippine General Hospital to see cases that are more common in our country. In return, they also host our trainees and faculty to see their patients and the different ways they manage them. It helps that my classmate from medical school at the UP College of Medicine, Dr. Bernard Macatangay, is an infectious diseases faculty member and researcher at Pitt. Beej, as we call him, is a rising star in the field of immunology and he is currently working on an HIV cure. The collaboration with Pitt has been a mutually beneficial arrangement, and after a brief pause during the pandemic, we have now restarted these exchanges.
One of the programs we revived recently is a joint medicine conference. Due to the time difference, we can only do these conferences in fall and winter when the gap between the time zones is 13 hours. We hold our conference at 7:00 a.m. while they hold theirs at 6:00 p.m. Eastern time. With people gathered in each venue, we connect online and the learning starts. We present one interesting case and they present another in the time allotted and we take turns with the discussion. Past cases from the Philippine side have included amebic liver abscesses which they almost never see in Pittsburgh. On the other hand, our Pitt colleagues have presented cases like Q fever which is not usually seen in our country.
The most recent iteration of the conference happened last January 12 (January 11 in Pittsburgh). Only a few of the current residents (doctors who have completed medical school but are training in a specialty like internal medicine) and fellows (doctors who have completed residency and are training in a subspecialty like infectious diseases) and some of the faculty members had participated in the last conference back in February 2020, just before the lockdown. I arrived at 6:30 in the morning to the PGH Science Hall to find the medicine team already setting up. The trainees and faculty started filtering in just before 7:00 a.m. and the Pitt team came on live.
The first case was presented by a Pitt infectious diseases fellow. It was a fascinating case of a patient with skin lesions that would not go away and progressively got worse. The patient ended up having a rare form of blood cancer that took a lot of work to diagnose. On top of that, the skin lesions were found to be infected with a hard-to-treat fungus which they detected with a very powerful and cutting-edge diagnostic test. They performed Next-Generation Sequencing (NGS) metagenomics in order to find the fungus. This entails taking a sample of the tissue and reading the sequences of all the DNA and RNA found in that sample. The technique tags and chops up all the DNA and RNA into little segments that can be sequenced quickly. With a supercomputer, you put the tagged sequences back together like a puzzle and compare them against a database of the genomes of thousands of organisms while filtering out the human DNA. While we do have NGS in the Philippines, we don’t routinely use this for patient care. It costs tens of thousands of pesos just to run one sample not to mention millions of pesos worth of equipment. The case was an eyeopener for our side because we learned more about rare cancers and new state of the art tools used for detecting infections.
Our case was an HIV patient with tuberculosis who had a very unusual complication. Because he kept coming back into the hospital with pneumonia, the pulmonologist was suspicious that he may have an aberrant connection between his esophagus (the tube that connects our mouth to our stomach) and the trachea (the windpipe which is the main connection of the lungs to the mouth). Whenever he swallowed food, some of the food particles ended up in his lungs causing the repeated bout of pneumonia. Since we see so much TB in the Philippines, we have seen these cases but clearly the Pitt people had not. We worked it up with a CT scan and we had a video of the endoscopy (a procedure where a camera on a tube goes down through the esophagus) showing the hole in the esophagus and showing cartilage on the other side which is what the tracheal wall is made of. The Pitt people were surprised by the diagnosis because they never considered that that was what the patient had based on their own experiences.
These kinds of exchanges enrich the training and practice of medicine on both sides. It shows that everyone in the world has something to offer be it from a rich or resource-limited country, but we will only benefit if we take the time to collaborate and discuss. With so much turmoil from wars starting so soon after the disruption brought about by the pandemic, it is such a shame that people aren’t more interested in working together within the global community. We can only keep trying and hope that people eventually come to their senses. Everyone needs to understand that when people come together with respect and an open mind regardless of race, creed or resources, good things will happen.