Global Forum seeks solutions to workforce challenges

Health leaders from around the world gathered at the American College of Physicians' 18th Global Forum during Internal Medicine Meeting 2025 to discuss changes in the internal medicine workforce and brainstorm collective solutions.

The forum was moderated by Mukta Panda, MD, MACP, Chair of ACP's Global Engagement Committee, and Irma L. Ceja Martinez, MD, FACP, Regent and Vice-chair of the Global Engagement Committee, with four panelists representing the Indonesian Society of Internal Medicine, ACP's India Chapter, the Royal College of Physicians, and ACP's British Columbia Chapter.

“Internal medicine remains the backbone of our U.S. health care system, with about 25% of practicing physicians in internal medicine in the U.S.,” William E. Fox, MD, MACP, Chair of the Board of Regents for 2024-2025, told attendees. However, he said, although internal medicine is the largest training program in the country, “there are some reasons for concern here in the U.S. about our workforce, as there may be in many of your countries.”

These include fewer internal medicine physicians choosing careers in the field and in primary care, medical students indicating they plan to use their degree for a career outside of patient care, and the resulting workforce gaps being filled by physician assistants and nurse practitioners.

The U.S. is exploring ways to allow qualified and internationally trained physicians to practice in the country, Dr. Fox said. But many countries around the globe struggle with their own workforce shortages and challenges, like fragmentation within the internal medicine field, rising workplace violence, and burnout.

Citing the similarities between nations' struggles, Mukta Panda, MD, MACP, Chair of ACP's Global Engagement Committee, reminded attendees that solutions can and should benefit the global physician workforce.

“We need to remember that these impacts and choices are not isolated. They have a powerful ripple effect, and that ripple is global, demanding a unified and strategic response,” she said.

Similar setbacks

To kick off the discussion on workforce challenges, panelist Sally A. Nasution, MD, PhD, FACP, President of the Indonesian Society of Internal Medicine, explained how in her country subspecialists thrive in major cities with well-established health care facilities, but this infrastructure is lacking in rural areas.

“Most of the patients rely on national health insurance while only a few use private insurance or out-of-pocket payment, which typically offers a broader coverage. This is one reason why many specialists and subspecialists prefer to practice in major cities, not only for the health care facilities, but the financial rewards are also greater,” she explained.

This has created issues in urban areas, where it's unclear when patients with complex conditions such as diabetes should be treated by a general internal medicine physician or be referred to an endocrinologist or diabetes subspecialist, she said.

Compounding personnel and access issues is the rising trend of workplace violence.

Panelist Anuj Maheshwari, MD, FACP, Immediate Past Governor for ACP's India Chapter, told attendees that violence can range from aggressive body language to verbal abuse, psychological violence, and explicit physical harm.

What's more, “the patient and doctors, when both are compared, the population has its sympathy towards the patient side instead of the doctor's side,” he explained. To combat any type of violence directed at health care professionals, Dr. Maheshwari stressed the importance of physicians prioritizing their own health along with that of their patients.

“Governments, lawmaking agencies, should understand that doctors' health and doctors' safety is as good and required as the patients' safety and patients' survival is required,” he said.

This underscores the importance of collective empowerment, which the next panelist, Mumtaz Patel, MBChB, PhD, President of the Royal College of Physicians (London), drove home in her talk.

“At the moment, physicians have lost their voice,” Dr. Patel said. She called for collective action to bring people together more effectively, creating an inclusive, supportive, and compassionate culture for physicians.

“A lot of my colleagues would feel things are imposed on them rather than that they've got a collective voice within that,” she explained, adding that if physicians' well-being improves, that will translate into better patient outcomes.

During his talk, panelist Scott McKee, MD, MPH, FACP, Governor for ACP's British Columbia Chapter, dug deeper into workforce trends that negatively impact internal medicine physicians' well-being.

There are three different career paths those who study medicine can choose to take, he explained: clinical work or direct patient care, nonclinical work that takes physicians out of the health care sector, and facilitated clinical work. The latter category consists of “MDs that either reduce or eliminate their direct patient care, but they absorb other roles that facilitate health care delivery,” Dr. McKee said.

To ensure that the growth of nonclinical roles does not contribute to a further shortage of physicians, he recommended promoting facilitated clinical experiences to keep internal medicine physicians within the system and potentially still involved in clinical care.

But to prevent doctors from pursuing roles outside of direct care in the first place, internal medicine physicians need to be paid what they're worth, and the clerical work that drives burnout must be reduced, he said.

“If your doctor goes nonclinical or facilitated clinical, it should be because they've got a special passion or special talent, not out of disenchantment with the daily grind,” Dr. McKee said.

Although some experts tout immigration as a way to boost numbers of internal medicine physicians in certain countries, Dr. McKee reminded attendees that “there's really a net-zero that happens if an internist moves from country A to country B; somebody wins and somebody loses. And the relative impact of those changes can be quite different.”

Global perspectives

Frederik C.J. Bester, MBChB, President of the Faculty of Consulting Physicians of South Africa, offered insights on the struggles his country faces. Currently, South Africa doesn't have enough physicians and is now facing additional hurdles thanks to recent U.S. funding cuts.

“The training facilities in the country are more with public medicine,” he explained. “So, one of the things that you can do, you can easily double up your training platform numbers” if you also train doctors in private facilities. In a similar vein, Harumi Gomi, MD, FACP, Governor for ACP's Japan Chapter, explained that in Japan, the government “created a medical school, private medical school, where we accept students, where students will go back to their local towns after appointed graduation. They have to serve in their hometowns for nine years given the waived tuitions.”

With regard to the fragmentation of internal medicine and increasing subspecialization, Global Physician Scholar and ACP Member Elizabeth Tomilola Emmanuel, MBBS, from Nigeria, suggested one solution might lie in how value is measured among health care professionals.

“A nephrology school [that] keeps a patient at [chronic kidney disease] stage 3 is undervalued compared to somebody who works in transplant medicine, for example,” she explained. “But for countries like my low-middle-income country, where people pay out of pocket, prevention is very important. Primary, secondary prevention, it's better for you not to need those big interventions because you won't be able to even afford them.”

Philip Kam-tao Li, MD, FACP, President of the Hong Kong Academy of Medicine, agreed that value needs to be more evenly distributed. “We also sort of stress and emphasize the importance of general medicine together with the specialties, so we do need all our fellows in the Hong Kong College of Physicians to have both internal medicine and specialty training,” he said.

This difference in perceived value can also translate into salary disparities. Dr. Ceja Martinez told attendees of a saying in Mexico: “Donde hay sangre no hay hambre,” meaning, “Where there's blood there is no hunger.”

“So people will go into the surgical [specialties] or will go into the ones where they can do more things that will also give them more money,” she explained.

Technological advances also hold promise. Omar Orlando Castillo Fernández, MD, MSc, FACP, President of the Panamanian Society of Internal Medicine, explained how telemedicine can help close the health care access gap between rural and urban populations. He continued to describe how in his hospital, an artificial intelligence chat bot helps clinicians address common patient concerns. Not only could this be an important tool for patient care, but it could also improve the well-being of doctors and prevent burnout, he said.

Ricardo Gómez Huelgas, MD, Immediate Past President of the European Federation of Internal Medicine, echoed calls for collective empowerment to combat care fragmentation. He called for “increasing the generalist skills in all medical subspecialties, and, at the same time, to enhance the role of general internal medicine.” Noting the myriad representatives from the world's largest internal medicine societies present at the meeting, he proposed working together “in order to try to harmonize the training [of] internal medicine, to harmonize the access to subspecialties and also to define better the role of generalist specialties.”

By working together, medical societies can also ensure patient care remains the foremost priority and address any ripple effects of decisions made in metropolitan countries, said Everard Barton, MD, FACP, Governor for ACP's Caribbean Chapter.

Angela C. Johnson, MD, FACP, Chair of the Board of Governors for 2024-2025, highlighted the recurring themes running through comments made during the session, such as providing reliable funding to train new physicians, balancing the importance of primary and general medicine with specialty medicine, and mitigating resource disparities between urban and rural populations.

“I can't decide if I am more disheartened or comforted that we all have such similar struggles,” she said. “But I'm definitely comforted by the energy of wanting to find those solutions and working together to find those solutions. … I'm only here once a year watching this happen, but I think it's beautiful and I hope that ACP can continue to play a role in making this [discussion] even more productive.”