ABSTRACT

KEYWORDS

Each country, community or individual has experienced the SARS-CoV-2 pandemic differently according to its economic, social, cultural, health, family and religious particularities. In any case, the pandemic has exposed the enormous flaws in the health care system of almost every country. In Mexico, a series of unfortunate elements converge in varying proportions, including an environment of limited resources where magical thinking, superstition, misinformation, commercial and political interests, poor accessibility to health services and a long and painful etcetera prevail. The simultaneous participation of these and other factors explains —at least in part— why Mexico is one of the countries where the SARS-CoV-2 pandemic has caused the most devastation.¹ In addition, Mexico is the country quintessentially characterized by reactive and insufficient responses to complex, serious and multifactorial problems.

Despite the adverse scenario, there are aspects of the SARS-CoV-2 pandemic that could be considered favorable and used to improve respiratory health. A pulse oximeter is now available in a large proportion of Mexican households. Thousands of people are familiar with the term "oxygenation", indeed, they even know relatively well the percentage of normal oxygen saturation that an individual should have. This phenomenon of medical self-education under the health pressure of the pandemic is favorable for identifying at least the tip of the iceberg of hypoxemic subjects. Although the use of pulse oximetry in the management of patients with COVID-19 did not improve survival,² current knowledge about oxygenation is something that increases the population's sensitivity to respiratory disease. The same happens with the current popularity of chest X-ray or chest tomography that should be used in favor of the identification of patients not only with COVID-19, but also with chronic respiratory diseases (CRD) and be able to decrease its enormous underdiagnosis. It is desirable to use the current knowledge of the general population about these diagnostic methods to identify a greater number of patients with lung cancer, fibrosing diseases, emphysema, bronchiectasis, etcetera. Parallel campaigns to identify such patients could be very successful by taking advantage of the inertia gained from the COVID-19 pandemic.

In general terms, in Mexico, 90% of people with CRD are not diagnosed. The burden on the health system that they represent is gigantic, since when they go to the hospitals, they are usually in advanced stages of the disease with very few options for successful treatment.³ In this sense, we must popularize other diagnostic tests related to respiration such as respiratory function tests and sleep studies.

Another positive aspect of the pandemic is that the general population's knowledge of the specialty of pulmonology has increased markedly. Until recently, people were well aware of the type of problems that an orthopedist, ophthalmologist or gynecologist treats; however, the specialty of pulmonology was practically unknown. Now, people know that the specialist in lung diseases is the pulmonologist. It seems a small thing, but in terms of medical education in the population, it is an ostensible advance. The population must create its own needs and demand the corresponding health services. The greater social recognition of the pneumology specialty is a factor that should be taken advantage of to manage human and technological resources for respiratory health.

Remote medicine —telemedicine or telehealth— is a beneficial strategy that has been greatly boosted by the pandemic. Most auxiliary diagnostic studies now have real-time connectivity to the internet; so that we can have oximetry, radiography, functional studies, tomography and sleep studies at our fingertips via smartphones. Artificial intelligence could even help in mass decision making without the need for a person to be on the other end of the line. The above represents unprecedented opportunities to advance respiratory medicine in our country and globally.⁴

Although from the point of view of health care, the participation of pulmonologists has been very important during the pandemic, their contribution to public health has been poor. The leadership of pneumologists should be a protagonist in public health decision making and health policies, in the distribution of resources, in the planning and implementation of massive respiratory health care strategies, in the development of research centers in emerging respiratory diseases, and in many other aspects such as the promotion of human resources training related to respiratory health. There is no doubt that there is a need to promote the training of pulmonologists and, for this reason, there are now a large number of training centers for pulmonologists throughout the country with direct entry; however, the strategy cannot only be quantitative, but also requires a qualitative approach. Once again, the reactive response appears, poorly planned, "on the fly", short term. The commitment cannot be as short-sighted as training more pulmonologists because Mexico needs them. More are needed, no doubt, but also better pulmonologists. Not only specialists who cover the primary need to care for patients, but also pulmonologists who are pioneers in their workplace or in their community, who teach, who are academics, who do research; in a word, who are leaders. A leader provides gigantic benefits to individual and collective health. These benefits often grow exponentially as the leader's professional development grows.

Current pulmonologist training sites created in the wake of the pandemic are poorly planned. They have one or two pulmonologists who are the professors and their program usually lacks university recognition. They do not have sufficient equipment to assist in the respiratory diagnostic process, that is, they do not have bronchoscopes, respiratory physiology equipment, diagnostic equipment for sleep disorders, etcetera. Staying in other hospitals does not solve the problem. Hospital centers that have all the diagnostic and therapeutic tools are not only overcrowded with patients, but also with trainees. Hand in hand with the above, there is the need to create more vacancies for pulmonologists in the country's public institutions. Training more pulmonologists on the fly without vacancies in the hospitals is nonsense. Every second level hospital should have at least one or two vacancies for specialists in respiratory medicine.

We must take advantage of the current situation of the pandemic and leave behind the conformist and mediocre thinking in order to promote pulmonologists in training as a priority. The history of the great Mexican institutions related to health was like that, betting on quality. Young specialists traveled to the United States or Europe with the support of the training hospital centers, to later return to exercise the intellectual leadership that contributed to the growth of the institutions and Mexican medicine. This has been almost completely lost. To remain with the idea that we are intellectually and technologically self-sufficient is, undoubtedly, a thought as parochial as it is arrogant. We may be self-sufficient in some disciplines, but when it comes to developing at the frontier of knowledge and technological advances, we need to expose ourselves to what is being done in medical and educational centers in developed countries. We must have the humility to understand and bridge the gap that separates us from those centers and, with everyone's talent, sublimate that gap and transform it into opportunities for growth. We must make respiratory medicine in Mexico evolve. Evolution implies, by definition, qualitative modification.

Now, with the pandemic on our shoulders, we must promote new generations of pulmonologists and bet on quality. This is the historic moment that Mexican pulmonology needed to take giant steps forward on the complex path of development. The urgency of the pandemic should not be the reason to put quantity before quality. The pandemic will not be solved because in five or six years we will have more pulmonologists with weak training and scarce vacancies for their recruitment. The vast majority of them will sadly join the large group of poorly competitive physicians we have in Mexico.

Management skills are the key. The greatness of the Mexican physicians who cemented the golden age of Mexican medicine was rooted in their management capacity. Ignacio Chávez, Salvador Zubirán, Donato Alarcón, Federico Gómez and all that generation of personalities, based their trajectory on the management capacity that their leadership granted them. They had the determination and perseverance to make things happen. From dreams they made realities. It does not matter if those professors were magicians when they hit the prechord or when they searched for the sign of the Pitres coin; their greatness was, without a doubt, their management capacity. They managed and achieved many things, but the most valuable aspect of their efforts —and common denominator in all of them— was the support and commitment to the quality of their doctors. Mexico owes them a golden era of achievements and successes that persist to this day. As Dr. Pelayo Vilar said in some of his splendid conferences: "I do not know if Mexico would be the same without the management of those giants of medicine, but what I am sure of is that it would not be better". How much we need that sense of leadership and that management capacity of those visionary doctors to move forward in the jungle of corruption and of a senseless Mexico.

REFERENCES

1. Coronavirus Resource Center. John Hopkins University. [Consulted 23 05 2022] Available in: https://coronavirus.jhu.edu/

2. Lee KC, Morgan AU, Chaiyachati KH, Asch DA, Xiong RA, Do D, et al. Pulse oximetry for monitoring patients with COVID-19 at home - a pragmatic, randomized trial. N Engl J Med. 2022;386(19):1857-1859. doi: 10.1056/nejmc2201541.

3. GBD Chronic Respiratory Disease Collaborators. Prevalence and attributable health burden of chronic respiratory diseases, 1990-2017: a systematic analysis for the Global Burden of Disease Study 2017. Lancet Respir Med. 2020;8(6):585-596. doi: 10.1016/S2213-2600(20)30105-3.

4. Stachel A, Daniel K, Ding D, Francois F, Phillips M, Lighter J. Development and validation of a machine learning model to predict mortality risk in patients with COVID-19. BMJ Health Care Inform. 2021;28(1):e100235. doi: 10.1136/bmjhci-2020-100235.