북한이탈의사 교육: 서울의료원에서의 경험을 중심으로

최재필,Choi, Jae-Phil 연세대학교 의과대학 2012 의학교육논단 Vol.14 No.2

As North Korea passed from the Devotion (Jeongseong) movement to the black market (Jangmadang) system, the medical service system in that country was effectively destroyed. North Korean physicians who have successfully defected to South Korea (North Korean defector physicians, NKDPs) have experienced socio-economic hardships on their way to becoming incorporated into the South Korean medical system due to different medico- social cultures, different (English-based) medical terminology, and the clinical knowledge gap between North and South Korea. Since 2009, we have operated programs at the Seoul Medical Center to help NKDPs prepare for the South Korean medical licensing examination. These programs consist of clinical education at the medical center, personal mentoring, arrangement of educational programs at the medical college, mock tests at the consortium, and administrative aid. Looking forward, we hope to achieve the following: 1) More systematic support plans are needed involving medical education experts, field physicians, and experts on reunification. 2) An evaluation of defector physicians' current medical knowledge may provide information about the areas where supplementary education is most needed and the standards for certificating licenses. 3) In the short term, a customized glossary should be developed to assist defector physicians prepare for the examination. 4) To secure internships and residencies is the most important issue for further sustained training of NKDP physicians to become good clinicians after certification. Hopefully, this short report on the current ongoing educational course will lead to more extensive discussion.

HIV 감염인을 위한 완화의료와 호스피스

최재필,Choi, Jae-Phil 한국호스피스완화의료학회 2017 한국호스피스.완화의료학회지 Vol.20 No.3

항레트로바이러스제 치료의 확립, 조기치료로 HIV 감염인들의 바이러스의 조절과 면역저하의 개선이 이루어지고 있다. 다수의 환자들이 더 이상 에이즈 관련 합병증으로 사망하지 않고, 심혈관질환, 대사성질환, 간질환, 신장질환, 신경계질환과 같은 만성합병질환을 갖고 고령화되고 있다. 그러나 지금도 여전히 사회적 차별과 낙인이 존재하는 가운데 후기 발현자로 후천면역결핍증 상태로 방문하여 사망하거나 중증의 신경계합병증으로 장애를 갖는 환자들이 있다. 환자의 다양한 증상들에 대해 이른 시기부터의 완화의료적 접근이 필요하다. 원위 대칭성 감각 다발신경병증 등의 환자의 만성 통증은 저평가되어 왔고 이에 대한 적극적인 통증 중재가 필요하다. 이전 호스피스 기준은 현재 시점에서 새롭게 제시한다. 감염인의 약제 지속 등의 의학적 필요, 심리적 상태, 사회적 여건에 대한 이해가 필요하다. 표준주의 감염관리 원칙을 준수한다면 만성질환으로서의 보편적 호스피스 진료의 제공이 가능하겠다. 생의 말기 빠르고 적극적인 호스피스팀의 개입을 통해 환자들이 존엄하게 삶을 마무리하실 수 있도록 임상경험이 늘어나고, 제도가 마련되길 바란다. According to the advance of antiretroviral regimen and the early treatment strategy, people living with human immunodeficiency virus (PLWH) are achieving the goal of virologic suppression and immune restoration. Most of them no more die of acquired immunodeficiency syndrome (AIDS) defining illnesses, and become older with chronic comorbidities such as cardiovascular, metabolic, hepatic, renal and neurological diseases. However some PLWH still visit hospitals as late presenters with very low CD4+ T cell counts, so that they suffer AIDS defining illnesses to die or experience severe neurological complications resulting in disabilities. Early palliative interventions are needed on the various symptoms of PLWH. Thus far chronic pains such as distal symmetric sensory polyneuropathies have been underevaluated. Active pain-relieving interventions are important to them. Recently we define end of life condition of human immunodeficiency virus (HIV) or eligibility to hospice care after adjusting current status of HIV treatment. Hospice teams should pay attention to the specific medical conditions, psychological needs, and social circumstances of PLWH. With just standard precautions as common infection control measures, general hospice cares can be provided to them like to other hospices subjects. For giving PLWH opportunities to have the end of life with value and dignity, hospice multidisciplinary team should intervene them early and aggressively. Now we need more clinical experiences and institutional improvements.

Dysphagia Lusoria 1 예

최재필(Jae Phil Choi),박효진(Hyo Jin Park),김정환(Jung Hwan Kim),김기중(Ki Joong Kim),유영훈(Yung Hoon Yoo),이상인(Sang In Lee),박인서(In Suh Park) 대한소화기기능성질환·운동학회 2002 Journal of Neurogastroenterology and Motility (JNM Vol.8 No.1

Dysphagia lusoria (swallowing difficulty due to trick of nature) is used to describe the symptomatic compression of the esophagus from any anomalous vessel of aortic arch. Aberrant subclavian artery, the most common anomaly of aortic arch can cause dysphagia lusoria by its direct compression of the esophagus or its aneurysmal dilatation. Patient with dysphagia lusoria can be treated with dietary modification, medications (antireflux drugs, prokinetics) in early symptomatic phase, and with surgical correction (via thoracic or extrathoracic approach) in late symptomatic phase or selective cases. We experienced a case of 44-year-old man who suffered from progressive swallowing difficulty for solid foods. We evaluated the possible causes of motor or mechanical dysphagia by esophageal manometry, esophagography, esophagogastroduodenoscopy, and chest computerized tomography. We finally diagnosed this case as dysphagia lusoria due to group 3 aberrant left subclavian artery.(Korean Journal of Gastrointestinal Motility 2002;8:63-67)

COVID-19 팬데믹 대응에서의 공중보건의료윤리: 관계적 자율성, 연대성과 돌봄윤리를 중심으로

최재필(Jae-Phil Choi) 국가생명윤리정책원 2021 생명, 윤리와 정책 Vol.5 No.1

본 연구에서는 Coronavirus 19 infectious disease(이후 ‘COVID-19’) 팬데믹의 지속 상황, 공중보건의료 임상현장에서 적용 가능한 윤리원칙으로 여성주의 관계적 자율성, 연대성, 돌봄윤리를 검토하였다. 한국의 상황에 대한 복기는 곳곳의 돌봄 실패 현상들을 드러내었고, 보건의료 종사자들에게 큰 돌봄 부담을 떠안겼지만, 노동이 저평가되기 쉬움을 알려준다. 관계적 자율성과 피해자이면서 매개체인 환자의 관점에서 볼 때 감염병에 이환되어 격리되는 시민은 사회적, 역사적 맥락 안에 배태되어 있고, 감염병의 생태학적 그물망 안의 연결고리로서 완화된 책임을 진 환자로 적절한 보호와 지원을 요청할 권리를 갖는다. 팬데믹 보건의료체계 안에서 의료종사자들이 함께 환자의 치료를 위해 확대된 의무를 수용하고 대응하는 연대가 필요하였다. 인간의 상호의존성과 취약성에 근거한 연대성은 목소리를 가질 수 없는 환자들의 배제 문제를 해결하지 못하며 돌봄윤리의 가치를 재검토하게 한다. 인간은 누구나 불가피한 의존의 보편적 경험이 있어 사회에서 의존 현실은 기본값이다. 보건의료종사자는 환자의 감염병 이환이라는 취약성에 대한 응답으로 돌봄 관계를 다시 형성하게 된다. 환자의 안녕과 회복을 위한 돌봄 관계의 지원이 필요하고, 돌봄 노동자로서 보건의료종사자가 취약해지지 않도록 지원하는 정책이 둘리아의 원칙을 통해 적극적으로 검토되어야 한다고 주장한다. In this article, the feministic relational autonomy, solidarity, and care ethics were reviewed as a likely alternative that is an applicable ethical principle during the COVID-19 (coronavirus) pandemic in clinical public health settings. Reconstructing the COVID-19 situation in the Republic of Korea revealed the phenomena of the failure to provide care everywhere and a huge burden of care for healthcare workers, which could be undervalued. A quarantined citizen who contracted the infectious disease is an agent who is also embedded in a social and historical context as well as a patient who has a reduced responsibility in the web of infectious diseases in the ecological relationships with others from the viewpoint of relational autonomy and the patient as a victim and vector. The citizen is entitled to ask for due protection and support. During the pandemic, health care personnel in the public health system needed to extend their solidarity in treating patients and responding to the pandemic. However, solidarity based on interdependence and vulnerability hardly solves the exclusion of the voiceless and require us to reconsider the value of care ethics. Everyone experiences universally inevitable dependencies, and so human dependency is the default value. Health care personnel build care relationships with patients in response to their vulnerability in contracting infectious diseases. Public support for the patient’s well-being and restoration is to be provided. However, I argue that support for public health personnel should be considered, so that they are not thrown into the vulnerable status, by applying the principle of Doulia.

한센병 병력자들의 C형간염: 유전자형 및 위험요인 연구

최재필 ( Jae Phil Choi ),이관식 ( Kwan Sik Lee ),이용제 ( Yong Jae Lee ),이충현 ( Choong Hyun Lee ) 대한내과학회 2006 대한내과학회지 Vol.70 No.1

비병원 장기 요양기관에서 입원하는 노인의 다제내성 그람음성균 보유

김민성 ( Minsung Kim ),신진호 ( Jinho Shin ),정연상 ( Yeonsang Jeong ),조진경 ( Jinkyeong Cho ),최재필 ( Jae-phil Choi ) 대한내과학회 2019 대한내과학회지 Vol.94 No.1

목적: 장기 요양기관에서의 입원하는 노인 환자들은 다제내성 그람음성균의 고위험군으로 여겨지나 병원이 아닌 장기 요양기관은 차이가 있을 것으로 예상된다. 이에 저자들은 비병원 장기 요양기관에서 입원하는 노인 환자의 입원시 임상 검체 다제내성 그람음성균 보유율을 확인하고 그 위험인자와 이들에 대한 항생제 사용의 적절성을 연구하였다. 방법: 2011년 4월부터 2012년 4월까지 서울 소재 623병상 규모의 공공의료기관에 병원이 아닌 장기 요양기관으로부터 입원한 55세 이상 환자 365명 중 감염성 질환이 의심되어 입원 후 48시간 이내 배양이 시행되었던 135명을 후향적으로 의무 기록 조사하였다. 결과: 상기 기간 동안 비병원 장기 요양기관에서 입원한 노인들의 입원시 임상 검체 다제내성 그람음성균 보유율 27.4%였다. 다변량 분석 결과 지난 입원시의 다제내성균의 보유만이 다제내성 그람음성균 보유의 독립적 위험인자였다(p = 0.043, OR = 5.00, CI = 1.049-23.834). 항생제의 초기 치료로 병합 요법과 카바페넴 사용은 35.6%의 환자에서 이루어졌으며 이는 사망률에 영향을 미치지 않았다. 결론: 비병원 장기 요양기관에서 입원하는 노인들에 대하여 보유 위험인자에 따른 적절한 항생제의 사용이 필요하겠다. Background/Aims: We investigated the risk of multidrug-resistant, gram-negative bacteria (MDRGNB) in hospitalized elderly patients from non-hospital long-term care facilities (LTCFs) and the antibiotic prescription pattern. Methods: All clinical cultures obtained within 48 hours of hospitalization from elderly patients of at least 55 years of age arriving at a 623-bed, public teaching hospital in Seoul, Republic of Korea from LTCFs between April 1, 2011 and April 1, 2012 were collected retrospectively. Results: During this period, 365 elderly persons from 13 LTCFs were hospitalized. This study enrolled 135 patients who had cultures performed. In this group, 27.4% harbored MDRGNB at hospitalization. The presence of MDRGNB during prior hospitalization was the only risk factor that predicted harboring it (p = 0.043, odds ratio = 5.00, confidence interval = 1.049-23.834). Combinations of antibiotics or carbapenems were used initially in 35.6% of the patients, and this did not affect the mortality rate in this population. Conclusions: Hospitalized elderly patients from non-hospital LTCFs need more attention. Judicious antibiotic selection is needed according to the risk factor of harboring MDRGNB for antibiotics stewardship. (Korean J Med 2019;94:107-113)

한국인의 기능성 위장관장애의 진단에 있어서 로마기준2의 유용성

지상원 ( Sang Won Ji ),박효진 ( Hyo Jin Park ),최재필 ( Jae Phil Choi ),이태희 ( Tae Hee Lee ),이덕용 ( Dok Yong Lee ),이상인 ( Sang In Lee ) 대한소화기학회 2003 대한소화기학회지 Vol.41 No.3

Background/Aims: The aim of this study was to determine whether symptoms of patients with functional gastrointestinal disorders (FGIDs) can be classified according to the Rome II criteria. Methods: Consecutive patients newly visiting Yongdong Severance Hosipital for evaluation of their gastrointestinal symptoms were recruited. Factor analysis was used to identify symptom clusters of the patients with FGIDs. Results: Among 274 patients, 207 patients (75.5%) had FGIDs. Thirty-nine of the 207 patients (18.8%) without organic diseases did not fulfill symptom duration defined by Rome II criteria, and other 168 patients (81.2%) satisfied the Rome II criteria. Factor analysis of symptoms of 168 patients indicated the symptoms of FGIDs such as globus, functional heartburn, dysmotility-like dyspepsia, irritable bowel syndrome, functional constipation, functional diarrhea, functional abdominal pain, functional fecal incontinence, and levator ani syndrome. Functional dysphagia and aerophagia could be regarded as one factor and functional vomiting and acid reflux could be merged as another factor. The proportions of patients suffering from functional esophageal, gastroduodenal, abdominal pain, bowel and anorectal disorders were 18.5%, 41.7%, 2.4%, 60.7% and 3.0%, respectively. Forty-one patients (24.4%) suffered from more than two symptoms of FGIDs, which belonged to the different anatomic region. Conclusions: The Rome II criteria could be applied to Korean patients with FGIDs. (Korean J Gastroenterol 2003;41:183-189)

증례 : 호흡기 ; 아시트레틴 투여로 발생한 간질성 폐렴 1예

김성두 ( Sung Du Kim ),김윤정 ( Yoon Jeong Kim ),고석찬 ( Seouk Chan Ko ),이호준 ( Ho Jun Lee ),최재필 ( Jae Phil Choi ),이헌 ( Heon Lee ),김수현 ( Su Hyun Kim ) 대한내과학회 2011 대한내과학회지 Vol.80 No.2S

저자들은 농포성 건선으로 아시트레틴 투여 후 발생한 간질성 폐렴 환자를 경험하여 문헌고찰과 함께 보고하는 바이다. Retinoids are effective systemic agents in the treatment of psoriasis. Acitretin, a synthetic aromatic derivative of retinoic acid, has replaced etretinate in retinoid therapy of psoriasis because of its more favorable pharmacokinetic profile, including a significantly shorter half-life. Most of the adverse effects associated with acitretin are teratogenicity, hepatotoxicity, pseudotumor cerebri, pancreatitis, hyperlipidemia, hyperostosis, and mucocutaneous side effects. There are two reports worldwide describing patients who developed acute respiratory distress syndrome associated with acitretin. This suggests the possibility of serious lung complications associated with acitretin. We report a case of a 61-year-old man who developed interstitial pneumonitis that might have been induced by acitretin during the treatment of pustular psoriasis. In these cases, immediate withdrawal of retinoic acid is necessary, and corticosteroid therapy should be considered. (Korean J Med 2011;80:S183-S187)

성인형 스틸병과 유사한 임상양상을 보인 다발성 골 결핵 1예

조진경 ( Jin Kyeong Cho ),김민성 ( Min Sung Kim ),신진호 ( Jin Ho Shin ),정연상 ( Yeon Sang Jeong ),김준완 ( Joon Wan Kim ),최재필 ( Jae Phil Choi ),최병용 ( Byoong Yong Choi ) 대한내과학회 2014 대한내과학회지 Vol.86 No.6

저자들은 전신 오한, 피부 발진과 관절통 등을 동반한 원인불명열 환자에서 성인형 스틸병으로 의심하였으나 흉추와 경골을 침범한 골 결핵으로 최종 진단된 증례를 경험하였기에 문헌고찰과 함께 보고하는 바이다. A 46-year-old man was admitted to our hospital because of a fever of unknown origin. The patient had a skin rash, arthralgia, and hepatosplenomegaly. Laboratory tests showed leukemoid leukocytosis, a high serum ferritin level (31,200 ng/mL), and abnormal liver function tests. He was initially diagnosed with adult-onset Still`s disease (AOSD). However, imaging studies incidentally detected a cold abscess involving the 11th thoracic vertebra. A biopsy of the abscess revealed histologically granulomatous caseous necrosis, positive for M. tuberculosis by polymerase chain reaction. We present a patient with musculoskeletal tuberculosis (TB) that clinically mimicked AOSD. In TB-endemic countries, extrapulmonary TB should be included in the differential diagnosis of AOSD. (Korean J Med 2014;86:785-790)