Interview: Arturo Dela Pena, MD (Surgeon, Administrator, Educator, Academic)

DelaPena

Arturo Dela Pena, MD is the Medical Director of St. Luke’s Global City. He is a man of many hats, being an active surgeon, administrator, academic, and educator. Contrary to the serious demeanor, it always does not take long for him to crack a joke. Yet, underneath the good humor, the man is complex in a positive and interesting way: you enter his room and on his table is a Michael Cacnio sculpture of an anonymous every day man kneeling and kissing the ground to give respect to a crown of thorns. He has Ricardo Semblar’s book Maverick, which is on the radical transformation of a company in Brazil, also on his table, and this is for Dela Pena the management man. Yet under the book is The Teaching of Buddha, and only a pile of papers separate Facility Management and Safety Manual and the book Moments with God, together with the latest bulletin and journals of his medical specialty. This self-professed fan of Rod Stewart and the Beatles is deadly serious when talking about medicine and St. Luke’s Global City.

You wear many hats: educator, administrator, surgeon, academic. Which one is the more prominent one right now?

The answer of course is administration takes up most of my time, and as a consequence I have to cut down on my clinical practice, yet I cannot say it is less prominent in my life, because I give the same time to each of the patient, and without a clinical practice, I will not be in touch with the patient, which is important to my work as an administrator, and without my role as an educator in PGH, I will not be up-to-date not only with what is happening in my field, which is rapidly changing, but I will also not be up-to-date as to the kind of residents and training they are getting . The explosion of data is just incredible, and if you are teaching in front of these young people, you just have to digest the data in a way that you are unlikely to do unless you are there in front of them. All these hats are important, and I cannot say one is less over the other, as administration must constantly be informed by all these.

Yet in research, which is very important, and I am involved with the team of Dr. Adriano Laudico, I cannot say my involvement now is significant, unfortunately. But let me say Dr. Laudico and his team are doing good and significant research on the relation of female hormones to breast cancer. That is the advantage of the younger generation physicians is their training recognizes the importance of this integration of the many aspects that make a good physician. Their academic subjects even in freshman medicine are already being connected to the clinical practice. I have a daughter in 2nd year medicine, so I can see the difference.

What do you tell your daughter who is a doctor? What is the most important thing that you tell your residents that will make them good doctors?

I tell them to learn from the patient: see the patient for what is actually there. Do not just have preconceived notions of what should be or what is said in the book. This is what distinguishes a good clinician from the rest. My father is a farmer, and it is my great misfortune that I did not keep the brown bags he was sending me with his notations about his referrals. He would write in Filipino, for example, “Arturo, apologies, but this patient is asking for help. Please help and see what you can do, as she is complaining about excessive bleeding.” Later on he will ask me what was wrong with the patient, and I will say it was ectopic pregnancy. After many people have come to me through him with his brown paper bag notations, his notation would suddenly say: “This patient is having problem with excessive bleeding, please see if she needs a D & C immediately.” For some patients, later, he will have a note like; “Please see if this is appendix, and it might explode soon.” So I keep telling young doctors, keep examining patients, no matter even if you think it is a simple case of pneumonia, because the more patterns you see, the better off you are in seeing patterns, and yet you also learn that solely relying on patterns is not good, as you also learn that each patient is unique.

How did a son of a farmer become the Medical Director of St. Luke’s Global City, become a leading educator and surgeon?

You know, I recall it now and I still get goose bumps. I remember helping my father in getting copra in Talisay, Batangas, when I was a boy and I tripped: I literally found myself falling face down on horse manure. I remember the anger I had because my father could not stop laughing at me. I was so angry and crying, I said he should not laugh at me. My father said, and I still remember this very clearly, when he said: “Arturo, if you do not study hard, you will just be like me and you will have to work with manure. If you do not want to be like me, only by doing well in school can you become different from me. Or else you will be like me, and your son will be like you.” You know, that turned my life around, and I am convinced, if my father had the privilege of having studied all the way in school, he would have been a great intellectual.

Thankfully you were still able to study in FEU for medicine. How were you able to afford it?

I got to use the education benefits that my father had because he was a guerrilla during the war. My father had a town mate who was the college secretary of FEU and so we decided I should go there. The youngest sister of my father also married a lawyer, and they helped and housed me. They were my parents here in Manila.

What is exciting you in the medical profession right now?

Everything excites me. The opportunities in medicine right now are quantitatively and qualitatively very different from when I was a young surgeon. We are now in a position to improve patient care.

So this is the about the generational change in leadership?

Yes and no. Yes, Dr. Edgardo Cortez our President and CEO is a real visionary. He is really implementing brave and innovative changes in the hospital. But aside from the generational shift, there is more competition, so everybody has to shape up, at the same time there is more data available, so there are real metrics from which you could measure the performance of an organization. This is all changing medicine and hospital administration in the country, all to the betterment of the patient.

Yet it is not just the generation shift in leadership that excites me. The developments in medicine, the speed at which we are beginning to understand diseases, it is astounding. The time may really come when we can predict diseases in a person long before any manifestation is apparent.

There are those who are saying, the competition, due to the entry of conglomerates in the hospital business, are also escalating prices for the patients. What do you think?

Yes, that is true, they are escalating their prices, because they are in health care for profit. That is fine, but also, because you want them to put money in health care to improve health care. Yet we also realize, doctors’ owned hospitals, non-profits, religious-owned hospitals, public hospitals, they also provide another vision of health care, not just the bottom line and excellent service, and I am proud and happy with St. Luke’s Global in that our vision is not just profit, although I have to say, any hospital that is not profitable, except for a government hospital, is not sustainable as the expenses are big and constant. Doctors have, I would like to believe, a different take on running a hospital, compared to, for example, a finance man, or a banker. We have I think over a thousand nurses here in St. Luke’s Global, because we have to allocate a certain number for many departments and functions for three shifts, and you also have to have a backup for the holidays and leaves that are part of the package for employment in a hospital. If you are not profitable as a hospital, it will not take long for you to close down. To say we give the highest standard of care is very easy to say, but many ingredients come into play when you want that to be a reality, from doctors, to geographic location, to the culture of the country. Finance is a big part of that mix as well, we have to admit.

Speaking of location, how are we compared to for example the United States in terms of health care?

Well, it is the most expensive health care system, and we should have learned by now that expensive doesn’t necessarily equate to quality, especially in relation to health care. It is not a question of money for me, because even if you have all the money in the world, are you using it efficiently, wisely, and logically? Because of defensive medicine in the United States, where they ask you to take a battery of test just to protect themselves from lawsuits, when in actuality you do not need the test, it is not necessarily good for you, never mind the waste in your finances. You requests these test for academic reasons? Yes, if there is a reason, but academic reason is vague and has been a blanket rational to just getting the patient to go through all the diagnostic equipment available and I don’t agree with that.

Now going back to your question about going to the United States for your health care; unfortunately health care is not like building a bridge where engineering can compute for you up to the last bag of cement that will be used. The hospital you can standardize the process, the physicians let us say we can even standardize the quality, but the patient, each patient is different from another, and how that disease will develop or evolve you cannot predict with standardization. Maybe you can predict 85 percent of the patients, but how will you know your patient is the 85 percent? For example, you can operate on a patient for breast cancer, and in your research you can do comparisons based on age, economic standing, and yet not all of them will fall into the data; yet your patient is not only not a statistic, but you don’t know which part of the statistic she falls into. Of course if the statistic says the survival rate is this, it doesn’t also mean you will die of cancer. You may die of something earlier or later for a reason totally not related to cancer that you have, so I will study the data, but I will be careful in extrapolating conclusions from the data.

The simple standard should be: there should be the same standard care you get, in the best hospitals in the United States and in the best hospitals in the Philippines, except their culture is very different from our culture. For example, in many clinics or doctor offices, you cannot just show up without an appointment. For example, our hospitals are adjusted to our culture in accommodating watchers or relatives staying overnight with the patient. In many private hospitals, we have the facilities, up to a common pantry that watchers or relatives find useful.

No doubt the United States has one of the most cost ineffective systems of health care, but with the case-rate payment scheme, it is shifting to an opposite extreme in reaction to the excesses of the past, and this has an impact on the decisions of many medical doctors. The most important is what is necessary for you to get well, and I am worried doctors may begin deciding on what is only possible based on your case rate.

Steve Jobs: did his wealth and access to the cutting –edge treatments extend his life?

Maybe. But I really don’t know the specific treatment. Difficult to answer: what measurements do you use as to the reactions of his immune system to the disease or the drugs? How can you quantify this? I know it is not a simple adenocarcinoma of the pancreas, it might be some slow acting tumor, since a neuroendocrine tumor is slower. Is it secondary to the treatment that he received? We don’t know. There is a lead time bias that is important. The latest issue of Time magazine , there is a mention about ductal carcinoma in situ ( DCIS )where it used to be treated with radiation and a removal of the breast, now no treatment is being advised, because it is now seen to be only a premalignant lesion. The disease process now is better understood, and that is also what I meant earlier that the opportunities in understanding of diseases are simply different now, and as a result better treatments are also improving rapidly.

What have you realized now as an administrator you did not know as a doctor?

When you are not part of administration, sometimes you just think of your needs, so you request for the best and latest and most branded equipment, not realizing the fact that the hospital has to spread out its income to many other needs and expenses. Running operations means more than just toys for doctors. Running a hospital also means running things efficiently and as economically as possible without compromising on the patient’s health. And this again is where metrics for service, finance, treatment outcomes all come into play.

Are you saying we have the data?

We will get there. The CEO of St. Luke’s, Dr. Cortez, made a decision of acquiring a data gathering system that will put the data in our hands. We have been going around the world looking for the best system, and we are beginning to narrow it down to only a few vendors. Of course having the best and most accurate data gathering software doesn’t mean anything if it’s too complex or tedious, then we won’t get the cooperation of doctors and nurses, and the whole thing becomes useless. We already tried to do it ourselves and to develop our operating systems, but you realize, the best hospitals and system developers took 20 or 30 years to finally get it right, so you go out and try to find a well-developed system that you can purchase.

Who are the most influential doctors in your career?

Dr. Antonio Limson and Dr. Adriano Laudico, who I always call the best chairman we never had. He was a visionary, like Dr. Limson. They had the vision to develop sub specializations in our field. They sent me to Toranomon Hospital for further studies. Of course in a way I have the best of both worlds, because PGH has the research and training, but there are limitations as well; and the opposite is what we have here in St. Luke’s, which has the private sector need for optimum efficiency, speed, and cutting-edge equipment.

Maybe this is changing? PGH has a big budget for equipment purchases.

I am not sure if a big budget necessarily equates with using your budget efficiently. In the area of purchasing for example, usually government hospitals allocate funds on the basis of democracy, when the more efficient way really is to define your strategic objective as an organization, have the whole organization buy into the vision of the leadership, and the purchases will be based on that strategic objective. I am not sure if you can run PGH on the basis of getting a wide consensus as to strategic objectives. This is not about democracy. Before you can do all that, you have to know your core competence, and you must know where you want to distinguish yourself as an organization. Strategic intent is the most basic for management to decide on purchases. But no doubt PGH has a very strong faculty.

I guess the next question will have to be what distinguishes St. Luke’s from the rest?

The leadership. The President and CEO here, Dr. Cortez, is a real innovator, and his direction is towards building a culture where people can be creative in solving problems. We have invested, through his efforts, on something that changes the treatment and chances of anyone who comes to us with ovarian cancer. Adenocarcinoma of the ovary, for example, we do chemotherapy intraoperatively, heat it up to 42 degrees and we find that the survival rate increases. Many hospitals are looking to wet lab and animal labs, but we went to Israel and bought a simulation system that helps our doctors have more opportunities in training. We are into robotics now as well.

How do you deal with death as a medical doctor?

With the patients, I think it should always be with sincere empathy, and with honesty. I have experienced the loss of my only son when he was only 21 years old, and experiencing something like that changes you in very definite ways: it is never the same anymore after something like that.

It is cruel for a doctor to give people a false sense of hope. It is unethical and immoral. One of my most memorable patients was brought to me by a friend. She comes from one of the rich families in the country. When I saw her, from her workup, I knew she had advanced liver cancer. I gave her the objective clinical diagnosis. She was stunned. She asked for her chances, and I told her the truth that short of a miracle, she did not likely have a lot of time in this world anymore. She thanked me. She said she was wondering why she was not getting well and all doctors were telling her she had this or that, like diagnosing her with hepatitis: nobody wanted to tell her the truth. So, after seeing me, she made her plan to go Lourdes in France, and she asked me for the necessary medical certificates, and she made her pilgrimage, made side trips to relatives living abroad. In fact I remember she asked me what she could get me in her trip to Europe, and I jokingly said one of those famous shirts that has a crocodile as its trademark. That was July. December, on a Friday, on her birthday, she kept calling me because I was the guest of honor for her birthday party, but I was too busy. That was the last time I had talked to her. March she was brought to the hospital for hepatic coma and she died. After two weeks, her two kids came to visit me. They informed I was in her last will and testament: it said that as long as they can afford it, I would get 12 Lacoste shirts every year. I started getting them every December, because she knew December is my birth month, and in fact, I still get them but I had to request, if they insist on giving me the shirts, they do it bi-annually or quarterly, so I don’t end up with the same sets of shirts every year.

Are you religious? You have spiritual books here on your table?

I came from a Catholic family and went to questioning the existence of God and becoming rebellious and wanting immediate social change, and I believe I have come full circle. I have come to believe that when there are no answers to questions, the answers maybe with something higher than us.

What books have you enjoyed that you would like to share with our readers?

Few people can write with social science data like Malcolm Gladwell. I have read Blink, Tipping Point, What the Dog Saw, Outliers. I would encourage people to read him. The very interesting book I always remember is by Captain Michael Abrakoff. His first book is It’s Your Ship, and he relates how he turned one of the worst-ranked US navy ships to become the top ship in the navy in efficiency, cost control, gunnery score in his two years of commanding the ship. It is an amazing book, on how he got feedback from the sailors on how to avoid the rusting of the metal, and he implemented it, and because of that, it meant less time for people devoted to repainting the ship and the time was allocated for some more productive endeavours. It is a simple management book but very good. I am looking forward to this book on my table, Maverick by Ricardo Sembler. It is another leadership book.

Are you a maverick?

No, I don’t think so. I would like to believe my leadership style is to always work within the rules. I think a maverick goes outside the rules. But more than anything, I hope to be remembered as a doer, that I do things that are assigned to me. That I get things done, and not just talk about them.

What is your definition of a good leader?

A good leader must first be a good follower. A good leader must be able to motivate people to get things done and to aim for higher things.