To future UNC student:

I highly recommend completing your Advanced Practice Selective rotation in Oporto, Portugal. I know 4th-year can be a hectic and expensive year already, but after you're through interviews, you must admit things finally slow down. Also, there are several scholarships available to supplement the cost of travel. If you enjoy traveling and living abroad, and are curious to work in alternate health delivery systems, Portugal is a fantastic option.  Dr.Felix and Dr. Basto, the UNC and HSJ physicians, are commited to coordinating an enriching and well-organized month for you.

Main entrance--Met Dr.Basto just inside on my first day

There are two blogs that I know of, created by previous UNC students, which have a wealth of useful logistical information for getting oriented to the city and planning your stay. I can't really add much more, except to say that you are more than welcome to email me with questions or concerns at jennifer.euna.lee [at] gmail [dot] com. I will also be doing a rotation at King's College London if you have any queries about that!

My team: Dr.Pestana (attending), Felipa (Intern), Joana (1st yr resident), Ana (6th/final yr med student), Catarina (2nd yr resident), me. Did I tell mention there's a 6:1 female:male ratio in medical schools in Portugal?

Useful links:

Chibuzo's 2009 blog: http://chibuzo-apsinporto.blogspot.com/ 

Garjae's 2010: http://apshospitalsaojoao.blogspot.com/

Hospital Sao Joao: http://www.hsjoao.min-saude.pt/PageGen.aspx?SYS_PAGE_ID= (google translate is very good here)

Official Porto Tourism: http://www.portoturismo.pt/

A nice food blog: http://www.foodandwineportugal.com/

Gastric banding included (sorry, no pictures)

I spent one day this week in the ambulatory surgical unit of Hospital São João. They offer numerous procedures such as arthroplasties, gynecological surgeries, hernia repairs, etc. on an outpatient basis for patients meeting strict criteria to manage risk. These include a certain level of health to optimize post-surgical outcomes, a phone to access urgent health care up 24 hours post surgery, an adult family member or caretaker, private transportation, and running water. During my day, I saw three gastric banding procedures.  It turns out that after a patient fails diet and exercise for weight loss, patients with morbid obesity can get public insurance to cover this procedure. I asked my residents what else could be covered, and they say that most things are—they’ve even heard of people “working” the system to have their breasts augmented due to “asymmetry”… Anyway, I thought I would delve a bit further on these unbelievable benefits of the national health program. I present my findings here.

As I mentioned before, the National Health Service of Portugal falls under the responsibility of the Ministry of Health and accounts for approximately 13% of the gross domestic product. As a working resident of Portugal, you are entitled to “free” basic health care under the Portuguese national health system including free essential medicines, free GP appointments, free treatments as well as partially subsidized (0%-60% subsidized) non-essential medical care.

Health Care Benefits: Theoretically, there are no services explicitly excluded from the NHS. That being said, in actuality, some types of care are not available in practice (i.e. 92% of adult dental care was in the private sector). General medical care for the adult population is provided by general practitioners, family physicians, or family care nurses to include services such as prenatal care, women and children, children’s care, family planning, first aid, certification of incapacity to work, home visits, and preventive services, including immunization and screening for breast, cervical and other preventable diseases. Patients are then referred to specialist for secondary and tertiary care services.

Out-of-pocket payment: In recent years, there has been an increasing use of co-payments to make consumers more cost-aware and to decrease abuse of the system.  For a flat rate, you have consultations (primary care and hospital outpatient visits), emergency visits, and home visits. There are also nominal fees for diagnostic tests and therapeutic procedures. Since January 2011, these fees increased to the following:

• Central hospitals - € 4.60
• District hospitals -€ 3.10
• Health Centers - € 2.25

Exemptions of co-payments apply for the elderly, pensioners, or patients with any of the following long list of circumstances (shame on USA):

Pregnant women;

• Children 12 years of age and under
• Children and youth with disabilities;
• Beneficiaries of a monthly allowance for life;
• Pensioners who receive income not exceeding the national minimum wage, their spouses and dependent minor children;
• Unemployed, enrolled in job centers, which receive income not exceeding the national minimum wage, their spouses and dependent minor children;
• Beneficiaries of any provision of nature by shortages, pay for services officers, their spouses and minor children;
• Residents of nursing homes for children and young people deprived of normal family environment;
• Workers on behalf of others who receive monthly income not exceeding the national minimum wage, their spouses and minor children;
• Pensioners with occupational disease and permanent disability
• Recipients of social integration income;
• Chronic renal failure;
• Diabetes;
• Hemophiliacs;
• Parkinson’s disease;
• Tuberculosis;
• AIDS patients and HIV positive;
• Oncological patients;
• Amyloidosis;
• Hansen's disease;
• Ankylosing spondylitis;
• Multiple sclerosis;
• Benevolent blood donors (provided they have made two donations in the 365 days preceding the date of access to health delivery, or if they are temporarily prevented by proven medical reasons, to donate blood, they have done previously donated five valid, or if they are permanently incapable, for medical reasons or documented age limit for donating blood, have previously made ten donations valid);
• Chronically mentally ill;
• Chronic alcoholics and drug addicts, when placed in rehabilitation programs
• Genetic disease with severe clinical manifestations;
• Congestive heart failure;
• Cardiomyopathy;
• Chronic obstructive pulmonary disease;
• Chronic active hepatitis;
• Cirrhosis with severe symptoms;
• Crippling arthritis;
• Lupus;
• Dermatomiose;
• Paraplegia;
• Myasthenia gravis;
• Demyelinating disease;
• Motor neuron disease;
• Patients with chronic diseases identified in the Minister of Health who, for medical criteria, call for appointments, tests and treatments are common and potential cause of early disability or significant reduction of life expectancy;
• Firefighters;
• Victims of domestic violence;
• Organ transplant patients;
• Living donors of organs, cells from bone marrow or hematopoietic stem cell;
• Potential organ donors of bone marrow cells or hematopoietic progenitor cells, in the provision of health services related to assessing the possibility of donation;
• Military and ex-armed forces personnel who are permanently disabled;
• Other cases prescribed by special legislation

Drugs: Doctors are free to prescribe any drug available on the Portuguese drug market, and almost all of them are partially reimbursed or totally paid by the NHS. The co-payments on pharmaceuticals vary from 40% to 100% depending on the therapeutic value of the drug. Full payment is usually expected to those drugs deemed to have little or no clinical value. Pensioners pay a reduced co-payment and the chronically ill are exempt from co-payments.

The following therapeutic classes are always fully covered:

• anti-diabetics
• anti-epileptics
• anti-Parkinson’s
• anti-neoplasm and immunomodulators
• growth and anti-diuretic hormones
• specific drugs for hemodialysis
• cystic fibrosis treatments
• glaucoma treatments
• hemophilia treatments
• anti-tuberculosis and anti-leprous drugs.

Additionally, all vaccinations in the National Vaccination Program are fully covered.

Excluding the medications above, pharmaceuticals are sold to the public according to the following classification scheme:

• Tier A - 90%; (ie, hormones and drugs for the treatment of endocrine diseases)
• Tier B - 69%; (ie, antimicrobials, cardiovascular drugs)
• Tier C - 37%; (ie, genitourinary system, allergenic)
• Tier D - 15%.

Obviously health care in Portugal is highly valued, and their culture of strong social systems makes access for even the poorest residents a priority.  However, the economic forecast of the country is questionable as the aging population grows, without robust immigration and a decreasing birth rate. The Ministry of Health will have their work cut out for them to implement a more efficient and sustainable program. When they’ve figured it out, perhaps they can let us in on the secret.

I’ve used the WHO’s HiT paper, the NHS official website (and a few conversations with Portuguese physicians) for this blog post. See below.

---

Bentes M, Dias CM, Sakellarides C, Bankauskaite, V. Health care systems in transition: Portugal. Copenhagen, WHO Regional Office for Europe on behalf of the European Observatory on Health Systems and Policies, 2004.

Portal da Saude. www.portaldasaude.gov.pt (National Health Service official website)

Million dollar view

Dr.Basto had arranged for me to spend a day at a recently founded private hospital just miles down the road from Hospital São João. I thought it would be an excellent opportunity to see first-hand the differences between the private and public sectors in the Portuguese health system. While I'm no expert in the inner workings of private hospitals in the US, I was nevertheless left nearly speechless after my day.

Hospitalcuf is new private facility opened in June of last year and has since been slowly opening its floors, specialties and services. Funded entirely by private businesses (banks, large corporations, etc), the 90 million dollar project has produced one of the finest, state-of-the-art facilities I have ever seen. With approx 180 beds, 8 ORs, an urgent care center, ICU, and all different types of imaging available at a drop of a dime(…or more), etc, this hospital has it all. To give you a comparison to the public sector, the infirmary ward in Hospital São João may have 4-10 patients per room at anytime. There are two mobile blood pressure /temperature/oximetry readers that the nurses and medical staff fight over every few hours and 5 computers in the doctors’ room (for all 20 residents).  Suffice it to say that resources can be a rate-limiting step. All the while, down the road in Hospitalcuf, there is one patient in one very well-equipped room overlooking the city, spacious private bathrooms, and extremely happy staff.

I imagine that private hospitals in the US are very similar, and I think again about the current trend to cultivate the private health sector in Portugal. Currently, the NHS is in a fragile state—as Dr.Ana Amorim, one administrator of HSJ said, the “budget is not enough, and it’s an unsustainable system.” The population is aging and the workforce is shrinking in a weak economy. Perhaps the private sector, in all its shiny glory is a necessary evil good. I can think of two ways: as a business, healthcare is an extremely profitable sector and can pump money into the fragile economy. Second, it can ease the strain on the public sector by redirecting those who are able to pay private insurance with their more comfortable amenities (not necessarily higher quality medical care). Additionally, Hospitalcuf may act as a competitor to the public healthcare, challenging and examining current standards of practice.

After a tour of the hospital with Dr. Bento Bonafacio, I spent the morning rounding with the internists and the afternoon observing two surgical cases. Their day certainly had a calm and quiet flow—although much of their tranquility can be attributed to the low patient load—the team was only taking care of 3 patients and there were 15 surgical cases (including ambulatory and GI procedures). I wondered if the paucity of patients was due to the recent opening of the hospital or that few people have private insurance. It may be a combination.

So long as public health sector does not get marginalized with the advance of privatized care, the development of this industry may prove quite beneficial and cushion the NHS and the Portuguese economy in the long run…only time will tell, and I wish the new hospital well.

High Quality of Life: There must be something in the water. Or maybe it’s just the port.

The ubiquitous pastry shops of Oporto fill their windows with their tempting concoctions of flour, sugar and butter. Every morning, patrons fill their shops and counters for their daily dose of caffeine and sugar. As a visitor, I have frequently indulged in the Portuguese breakfast experience, skipping my usual bowl of oatmeal. While I’m happily narrowing down my favorites (Pastel de Nata and bolo “de Arroz” and “de Berlim”), I admit I feel a passing moment of guilt as I remember my health and my family history of diabetes.  This prompted me to learn more about the dietary and other social habits of the Portuguese and their effects on their health as a nation. I’ll try to give a brief summary.

Food

As I mentioned, breakfast (if taken at all) is eaten in a shop and consists of a 2oz cup of espresso with a sweet pastry. A small snack in the early afternoon of more coffee and more bread usually tides people over until lunch at 2. Usually the biggest meal of the day, lunch starts with cheese, cured meats, olives, and bread followed by a generous plate of fresh seafood, traditional salted cod or succulent meats with boiled potatoes or fries. Enjoyed with wine and almost always followed by coffee or desserts, it’s no wonder that dinner is often very late (9-10p) and rather light.

Besides the amount of refined sugar, the Portuguese enjoy a fairly balanced diet. In fact, the Portuguese will be the first to tell you all about the benefits of their diet rich in omega-3 fatty acids and heart healthy wine. Unfortunately, diet alone is not able to maintain good health. Rates of adult-onset diabetes and obesity are increasing in Portugal, but individuals are slow to adopt a more conscientious diet. Sugar substitutes are rare in grocery stores as are alternates to sweet pastries in coffee shops.

Exercise

Generally, European countries are idyllic for pedestrian commuters. Public transportation runs efficiently, and can be more affordable than paying petrol by the liter. It’s said that Europeans are slimmer because of the extra energy expended as compared with their American counterparts. However, Portugal is a bit different from other European countries I’ve visited. The terrain is much more mountainous, and the city streets are steep and undulating, making travel by car more practical. Accordingly, the Portuguese are slightly heavier than other EU countries (Norway 10% obesity rates, Italy 9.8%, Germans 12.9%¹). While certainly not as obese as Americans (33.9%), the Portuguese (14.2%) must consider incorporating more active forms of exercise in order to stabilize the nation’s obesity rates. Asking my residents, they agree that exercising is not as common among older generations. However, young people are getting memberships to the growing number of gyms in their cities. Americans should take note.

Smoking

The leading causes of death in Portugal are (1) cerebral vascular disease and (2) ischemic heart disease. Along with dyslipidemia, diabetes, and hypertension, an important risk factor for vascular disease is **smoking**.  Most Portuguese are aware of the hazards of tobacco use and do have lower rates compared with other EU countries. Yet, tobacco rates are increasing, particularly among the female population. In men, 39.9% aged 25-34 and 44.6% in 35-44 smoke, while in women rates are slightly lower at 17.6% and  21.2%, respectively^2,3. While I haven’t questioned all the residents on my team, I’ve had 3/5 admit they were smokers. I was astounded by the number of smokers and the social acceptability of its practice. But then I remembered the long history of US anti-tobacco campaigns; and smoking rates started decreasing only decades later.  

I also going to discuss alcohol consumption and sleeping habits of the Portuguese, but I’m afraid this entry is already too long. Instead, I’ll leave you with some photographic rationale for doing a rotation in Porto. Like the title says…quality of life is ranked 19^th out of 111 nations⁴.  Here’s to everything in moderation(well, except tobacco)!

Every 5th storefront

Bolo de Berlim (...must...moderate...)

simple. fresh. wonderful. (and cheap!!)

If you like wine, you will definitely appreciate the Portuguese varietals.

1. Statistics from the WHO Global Database on Body Mass Index

2. OECD. Health at a Glance 2009: OECD Indicators. OECD Publishing, 2009. p52.

3. Precioso J, Calheiros J, Pereira D, et al. Prevalence and smoking trends in Portugal and Europe. Acta Med Port. 2009 Jul-Aug;22(4):335-48.

4. Economist Intelligence Unit. (2005) The World in 2005. Retrieved 12 January 2011. http://www.economist.com/media/pdf/QUALITY_OF_LIFE.pdf

A Portuguesa!

By paying close attention to the advice given from my predecessors Chibuzo and Garjae, I arrived safely and settled quickly into Porto and the Hospital São João. I am certainly appreciative of their insights (such as the monthly metro card and the café pingo), as they’ve helped me to step right into my new life and new rotation in Porto. Through this blog, I hope to share my own experiences and thoughts on working in the national healthcare system of Portugal and perhaps even share my own insights to facilitate the transition for future UNC students.

I thought I would start this blog with a brief introduction to the Portuguese health system and touch on current health issues of the nation.

The National Healthcare Service (NHS) of Portugal

In 1989, the government of Portugal passed a law that would protect the health status of its citizens through the establishment of governmental agencies and health service providers. Under this law, all tax-paying citizens* (and family members) are entitled to medical care for a nominal fee, although most people are exempt from payment (pregnant women, children, unemployed, patients with DM, TB, CHF, MS, alchoholics, blood donors…or any ICD9 code, it seems...)

Under the Ministry of Health, the NHS is comprised of hospitals, local health centers, and ancillary medical services.  The Ministry also sets the National Health Plan (NHP) to direct health priorities and health goals for the nation, including guidelines for standards of practice. The top current programs include the prevention and control of cancer, cardiovascular disease, mental health, and HIV/AIDS-- consistent with the nation’s most frequent causes of mortality (top five include cerebrovascular disease, ischemic heart disease, DM, and colon cancer).

Like any other dynamic and improving healthcare system, the NHS has a history of continual reform. Recently, there has been increased integration with the voluntary private sector to increase efficiency and decrease waste, as well as improve overall cohesion of health services. With the global economic downturn in 2010, Portugal will undoubtedly feel the constraints of the necessary austerity measures which will tighten the belt of most social services throughout Portugal. Unfortunately, Portugal is also an aging population with a shrinking workforce and even lower birth rate. This is very much like the economic issues that America will face in 2011 as the Baby Boomers start retiring, making them eligible to Medicaid and Social Security benefits. With the new Republican House of Congress challenging the Health Reform Bill of 2010, it will be interesting to follow the events unfold for Portugal, the US, and the rest of the developed world.

For the eager beavers who want to learn more about the Portuguese NHS, go to their website at http://www.portaldasaude.pt.

*Medical coverage of EU residents and foreigners may be covered by the national healthcare system as well. Separate rules apply, but this is beyond the scope of this brief introduction.  

I realize this is a rather dry entry for a traveling blog…next time I’ll try focus on something a bit more palatable—food and wine and health in Portugal! (As well other daily habits...tobacco and exercise). I'll leave you with some pictures to spice things up.

Faro

 (Sorry, I didn't have any people-less pictures of Faro)

Lisboa

Porto

Porto-Unreal, isn't it?

falling

35°N seemed so long ago.

On August 14, I got married to a wonderful man in Clemmons, North Carolina. It was a typical hot and sticky summer day, and it's already faded into a memory...a sweet dream of clinking ice in the sweet limades, layers of white poofy organza and laughing faces whom you can't quite make out.

Two months and 5 countries later, my new husband and I have finally settled into a cozy flat in the middle of London, just steps from the British Museum and the best chippie in the town(North Sea Fish). Here at 51°N, the summer sun is already fading fast and the trees are just touched with the turning colors. Everyone and everything seems to be clinging to the last bits of warm sunny days. Maybe they know something I've only heard about...the dreaded rainy and gloomy London winters.

I join the rebellion against summer's end!--no black tights nor brown scarves, warming cinnamon or nutmeg! For as long as I can, I will savor the late summer blessings with sweet pears, crisp apples, and the delicate flesh of plump figs..with a glass of white wine in the park.

Tanglewood Park

Clemmons, NC

Oxford, England