International colleagues face familiar problems

The American College of Physicians has 154,000 members. Of these, approximately 10% are international members. My role of President includes traveling to chapter meetings, both national and international, and representing the College at international internal medicine meetings. This aspect of the role provides me with a broad perspective of the opportunity that our international presence can bring.

As physicians, we know that we live in a global health care community. We know that continuing medical education takes place globally, that more than 60% of medical articles in top-ranking journals come from investigators outside the United States, and that one in four physicians practicing in the United States is an international medical graduate.

The globalization of health care is not new. Many major academic centers and medical societies have an international presence that focuses on partnership and collaboration to allow colleagues to learn more locally and expand leadership opportunities while helping patients get better care close to home. More is possible. As I've traveled for the College, I've been struck by the opportunity for collaboration, by the great goodwill for the College, and by the opportunity for meaningful global partnership.

As I've engaged international colleagues, I have been impressed with the similarities that we face as internists. The conversations taking place at international medical meetings could be taking place at your chapter meeting. Training on bedside ultrasound, end-of-life conversations, and the new diabetes guidelines are common topics. We are a global community.

Young physicians from all countries are seeking greater collaboration and partnership between specialists and subspecialists, between ambulatory-based and hospital-based physicians, and across the oceans that divide us. Colleagues are talking about implementing the Choosing Wisely program and developing local priorities. Wellness, civility, and quality of life for patients and clinicians both are persistent themes. Similarly, we all share concerns about privacy, appropriate use of technology, and the growing impact of administrative burdens.

As an example, the 34th World Congress of Internal Medicine (WCIM) was recently held in Cape Town, South Africa. There were two ACP-International Society of Internal Medicine (ISIM) sessions. One focused on medical education, and one focused on standards. These sessions revealed that we are all struggling to answer the question, “What is an internist?” Also discussed was the fact that the decline we've experienced in general medicine interest in the U.S. has been experienced worldwide, has been associated with a surging interest in subspecialty care, and has not resulted in better patient outcomes. Our fragmented practice has left the patient without a clear sense of whom to turn to for care.

In his keynote speech, Aru W. Sudoyo, MD, PhD, FACP, outgoing ISIM president, a medical oncologist, and President of the Indonesian Society of Oncology, talked about these being dangerous times for our profession and challenged us to thoughtful action. European colleagues commented that the fragmentation in care had spurred patients to request more time, more explanation, and more connection with the general internist.

Patients are demanding general internal medicine care. I met several subspecialists from Turkey, Austria, and Switzerland who were first-time attendees at the WCIM and who cited this very fact as their reason for attending. They usually attended their subspecialty meetings, they explained, but it was their patients' requests for a “main doctor” that was making them rethink their role and was sparking their interest in general internal medicine. Patients in the U.S. may share many of these same priorities. The changes that we are witnessing from afar may provide us with insights and opportunities for better communicating our message.

What did we learn at the ACP-ISIM sessions? We outlined the differences in our educational pathways. There is no one pathway to the medical degree. A significant difference is the requirement of a baccalaureate degree for entry into medical school in the U.S., whereas students in most other countries effectively enter after high school, with a shorter career pathway and a significant difference in cost. We spoke about the education of an internist and how it shapes our identity and defines what we do. We spoke about health care workforce needs. What is the right number of medical schools to produce the necessary number of physicians? What are the incentives and disincentives that cause us to produce too many or too few physicians? We discussed the role of market forces in shaping our profession, such as the push to subspecialize, the location of practice (outpatient or hospital, rural or urban), and the importance of lifelong learning.

This conversation flowed well into the discussion on standards. How do we know that the “lifelong learning” that one is doing is enough? We outlined the processes in our different countries related to licensing, certification, credentialing, privileges, quality measures, and performance measures and discussed the importance of competencies in these discussions. There was an important link among professionalism, competency, and assessment. How can the assessment of a professional be more accurate or more real when it is tied to a competency evaluation, to what we do every day?

And, of course, we discussed the incredible importance of measurement. Measurement can masquerade as science. What we choose to measure is profoundly impactful. Since some measurement is easier, for example, knowledge questions, that is what we tend to measure. Measurement of processes—how one accesses and uses medical information; how one engages with patients, families, and colleagues; and how one stays up to date—may involve more complex metrics that are therefore never measured despite their meaningfulness to patient care.

ACP and ISIM will be drafting a summary of these presentations along with additional thoughts to keep this conversation moving forward, so that our profession is not developing in reaction to market forces but is evolving with the needs of the patient in mind.

The 2020 World Congress of Internal Medicine will be held in the Americas, in Cancún, Mexico. Our similar professional challenges provide an opportunity for collaborative learning and sharing of best practices. Colleagues are interested in partnership, bidirectional exchanges, and a greater presence on committees and councils. They are reaching out to ACP to engage, contribute, and learn together. Members grow when they feel welcome, at home, and engaged in topics that speak to them. The College has an incredible opportunity to embrace the collaborative potential internationally. The door is wide open.