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ACP's international presence promotes better clinical care

From the February ACP Internist, copyright © 2017 by the American College of Physicians

By Nitin S. Damle, MD, MS, MACP

One of the joys of my year serving as ACP's president is the opportunity to learn about health care around the world. In the past six months, I have been to Panama City, Panama; Amsterdam, The Netherlands; Bali, Indonesia; and most recently Doha, Qatar. All of these invitations have been forged by over 100 years of College leadership in medical education, ethics, and high standards in the practice of medicine.

Though we may be the American College of Physicians, we have significant international presence. ACP's first international chapter (region) was formed in Canada in 1927, followed by Central America in 1928. Since then we have added 17 chapters, including Japan, Chile, Gulf, South Asia, India, Bangladesh, and most recently the Caribbean. International internists are growing and represent 10% of our membership. These members value our educational material, such as Annals of Internal Medicine, DynaMed Plus, newsletters, ACP JournalWise, IM Essentials, and of course our marquee product, the Medical Knowledge Self-Assessment Program (MKSAP).

International members seek continuing medical education through chapter meetings and international conferences, and they look forward to ACP speakers presenting plenary and workshop sessions and keynote addresses. In addition, around the world the practice of medicine is an honor, and internists seek recognition for their career accomplishments. I am asked frequently about advancement to Fellowship and Mastership by many qualified candidates.

Early-career physicians, residents, and fellows seek advice from the College about career advancement and opportunities in their own countries and in the United States. They also seek opportunities to display their research or clinical work as speakers at poster or vignette sessions and participate in “Jeopardy”-type competitions at the chapter and national level.

Since 2004, the ACP International Fellowship Exchange Program (IFEP) has been providing opportunities for early- and mid-career physicians from outside the United States and Canada to gain expertise in focused areas relating to internal medicine and the subspecialties. Through a four-week fellowship with a faculty mentor in the United States or Canada, the IFEP awardees acquire knowledge, experience, and skills that they can apply, utilize, and disseminate to colleagues upon return to their home country. This competitive program offers three positions per year. I have received many requests for expansion, and we are looking at this possibility.

Two of my talks to international members are an immunization update and an update on cancer screening guidelines for 2016-2017. I present these topics in a melded didactic and question-and-answer format that attendees find very engaging. But more important, they look to the College and its representatives to set the standards of care and knowledge and to provide clinical guidelines. Even with limited resources, the international community aspires to meet standards set by the College.

Various nations are at different stages of health care delivery. In the less developed world, the primary issue is access to care. There is inadequate primary care and lack of affordability for advanced diagnostic medical technology and therapy, while at the same time the clinicians are extremely knowledgeable, capable, and willing to serve.

Some nations have developed insurance coverage that has improved access and introduced technology and specialty care. However, they now recognize the cost associated with lack of primary and coordinated high-value care. Other nations have recognized the inadequacy of piecemeal payments for care delivery and have begun to make global payments to clinicians and health care systems for panels of patients adjusted for demographics and complexity. They have also instituted some level of price control, resource allocation, coordinated care, and payment proportionate to the value of care. I have not seen any countries that index payment to performance measures, cost of care, or shared financial risk with clinicians. Not surprisingly, most nations face the challenges of an aging population, including increased incidence of chronic illness such as obesity, diabetes, heart disease, and malignancy, and are struggling to address them.

I was recently invited to speak at the 3rd Annual Internal Medicine Conference in Doha, Qatar, along with Darren Taichman, MD, FACP, Vice President and Executive Deputy Editor of Annals of Internal Medicine, and Trish Perl-DeLisle, MD, MSc, FACP, Jay P. Sanford Professor of Medicine and chief of infectious diseases at UT Southwestern Medical Center in Dallas. We were very impressed by the quality of the faculty presentations and the oral and poster sessions. Qatar has significant natural resources and economic wealth. It is in the formative stages of improving health care delivery and at present provides its residents with government-sponsored health benefits. The country has a golden moment to create a system that is equitable, fair, high quality, and affordable. Dr. Taichman and I met with the department of medicine and graduate medical education and offered some unsolicited advice about uniform, not-for-profit insurance coverage; a strong primary care workforce with appropriate payment; high-value care; control of prescription medication costs; and the practice of population health. The physicians in Doha were very receptive to our perspective and will hopefully advise the Ministry of Health on these matters.

What have been remarkable are the kindness, generosity, and hospitality of the people I have met in my travels. A common thread is simple gratitude. There is gratitude for the opportunity to be educated, to be in a profession of lifelong learning and challenge, to have the privilege of caring for patients and to be witness to their joys and sadnesses, and to value the respect and authority given to physicians to change people's lives for the better. To quote Marcus Cicero, “Gratitude is not only the greatest of all virtues, but the parent of all others.” The complex problems and solutions of burnout in our profession have an element of simplicity. That simplicity lies in the recognition of our privilege, a vision for our professional and personal lives, a philosophy about life, and gratitude for simply being a doctor.

The College needs to continue to expand its presence around the world as a leader in medical education and clinical care. There are very few U.S. organizations that have not or will not establish an international presence in this technically connected and interdependent world. I look forward to the rest of my year as your President in representing the College in my visits to Taiwan, Chile, Japan, Uruguay, Australia, and India.

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