Interview: Dr. David Kershenobich Stalnikowitz – General Director, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico

dr-david-kershenobich-stalnikowitzDr. David Kershenobich Stalnikowitz, General Director of the Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán on the myriad issues surrounding diabetes in Mexico and how the Mexican healthcare system can evolve.

You have highlighted the importance of the institute operating as a reference center. What have been some of the new changes and research programs you implemented to maintain this positioning?

“Our research has generated key material to educate physicians, as well as patients.”

We have different projects in the diabetes field that are displaying excellent results. We are applying an integrative and comprehensive model. You have probably heard of it before, but now we have compelling data that shows that around 95% of the patients accomplished good glycosylated haemoglobin below 7. We have been able to successfully reduce the vascular events in the feet and recognize and detect changes in the vascular system of the eyes. At least 30% of the patients that we treat already present some type of lesion to the ocular system. Our goal with the early detection is to prevent retinopathy. A very important aspect of our project is to educate other general physicians; we have been able to do so by creating a very challenging online course that consist of 20 cases. To this day, we have certified a significant amount of physicians that work outside the institute. The outreach of education has become very important. We have not only been able to apply our method inside the institute, but across the country. Our research has generated key material to educate physicians, as well as patients.

The Mexican industry considers that there is a lack of education of doctors capable of diagnosing and treating diabetes. How are you working on targeting this matter?

We are educating and certifying physicians outside the institute with our online courses. In addition, we are working in Tlalpan’s delegation with 5 clinics to implement the system and see if we can replicate the same results we have seen before. We are very selective with the physicians we certify because we want to warranty that the system is being implemented correctly. We are also expecting to create matrixes to further study in which patients the system work and in which does not. We are working with the Fundacion Slim as part of the MIDO program. With this platform, we intent to test the relatives of the patients we receive. The testing includes for example blood glucose and arterial hypertension to understand if they need to be referred to a specialist. The relatives of patients with diabetes are at a higher risk of developing diabetes than a person with no family history of diabetes. Therefore, by testing this part of the population we can prevent and treat patients in the early stages of diabetes.

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This is a comprehensive program that involves visiting an endocrinologist, an ophthalmologist, a nutritionist, a personal trainer, and a psychologist. This way we gain insight about the habits of a person and try to change them to a healthier lifestyle. In addition, social media is playing a great role for physicians in the battle against diabetes. We are able to stay connected with the patients, to send useful information, images and also to connect with other specialists, which is helping us integrate all the parts of the program.

“The common word for all is responsibility”. When we see half of diabetic patients in Mexico are under control, do you think there is a lack of shared responsibility in the patient-physician relationship?

Responsibility goes in different ways. First of all, time is a tremendous factor when talking about a chronic disease, such as diabetes. To make a real impact in a patient’s life, the physician has to invest a significant amount of time and the patient has to completely change his lifestyle.

The second part is the social life of the patient. Learning how to socialize with diabetes is key on the evolution of the treatment.

I would also like to mention that our research is still on going. The institute completed a research in the past that identifies the Mexican population as more susceptible to diabetes and obesity. By doing metabolomics and proteomics, we are trying to identify the genetic components that determine the disease.

Our second program, an inclusive core lab, has been very productive. We have been able to publish 16 scientific papers in a year. Also, in our comprehensive approach to diabetes we are expecting to add a metabolic unit by the end of the year. We are going to have the clinical model, the research lab, and a metabolic unit to investigate in patients from clinical orientations to more basic research.

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Diabetes is a very complex subject in Mexico. From one side, you have the genetic predisposition of the population while on the other side, you have poor diet habits and a reinforcing society. We strongly believe that society is having a big impact by making bad food choices acceptable. Obese patients tend to have obese friends, allowing them to perceive as normal their poor diet decisions.

What is the best way to deal with a chronic disease, such as diabetes?

The best way to deal with the problem is prevention. At the institute where I work, they were set to treat the main complications of the disease. In the recent years, we have realized that we have to incorporate prevention to the equation. We not only have to focus on the prevention of the disease, but also on the complications of it. We have to change the mentality of the disease and implement prevention all the way to third level institutions, where it is even easier to implement because they posses a broader understanding of diabetes.

The main role of third level institutions is to educate, in good clinical manners and quality. I believe that regardless of the institution level you are working at, the job has to have great quality and be measurable. For example, it should be very well documented how many of the patients that had high blood pressure no longer have high blood pressure. We need metrics in everything that we implement.

What are the needs in the Mexican healthcare system?

First of all, many of the patients are forced to go to the private sector because the public sector is saturated. There has to be a communion between the population and the access of services, especially for chronic disease. In addition, I would like to see more investment in research to treat chronic renal damage. I think that the current approach is very archaic and in 20 years from now, we will wonder why we used to take such an approach. I cannot emphasize enough the importance of prevention.

To identify early onsets of chronic renal damage, we have to put in place biomarkers. We are now in the process to patent one that helps detect kidney damage at an earlier stage. Until now, we only use creatinine as a marker, but when the levels of creatinine are elevated it is already too late. Furthermore, the way we treat these patients has to be different too so they don’t go to a chronic kidney damage state. The only treatment we have for people presenting that kind of damage is replacement of the organ, which is very complex and difficult. This matter is of high priority to Mexico, where we have the largest amount of patients with dialysis of the world.

As we come close to the end of your mandate, what are the objectives you want to accomplish?

For my last 10 months, I would like to see some of the projects that we have started being implemented. During the time I have been working in the institute, we saw a lack of innovation, especially in pathology. The way we are seeing pathology now is in the molecular aspect. We not only see the disease in macro aspect, but we are personalizing the treatment we are using with patients. I hope that by the time I finish my term as director, the pathology department advances in its development.

We have also made significant changes in the emergency unit. Initially, our emergency unit had 350m, and now it has 1600m. We didn’t change the numbers of beds or nurses, but we changed the system of our unit. We have divided the waiting rooms into 4 different sections, where we place the patients depending on their needs. By implementing this system, we can provide our patients with better care. Our objective has been to maximize the efficacy our installations, and while we have done a great improvement, we can always do more.

You boast more than 500 publications, of which 182 are original articles in international journals, you wrote more than 50 book chapters, you received the Medal of Merit in Science and Arts 2015. Beside this national and international recognition, what would you like to be seen as your contribution to the Mexico’s public research system?

I would like to develop a model of attention as well as model of reference in research that have a positive impacts on the health of the entire country. I believe that by generating research, we are going to be able to attack the problems of the faulty system. Now we have an open innovation office within the institute, we are working on three different patents and I hope to see this number increase in the coming years.

What has been your proudest moment as director of Instituto Nacional de Ciencias Medicas y Nutricion Salvador Zubiran?

Seeing a patient being treated successfully and being grateful for the care they have received makes me proud, even more so when patients have been treated in other institutions unsuccessfully at an earlier stage. We have a very successful liver transplant program with more than 50 transplants a year. Speaking beyond numbers, the importance of our program lies in the successful training of physicians to actually perform the transplants.

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