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International Medical Graduates

Challenges in Medicine

Challenges in Medicine

S. Paul Handa, MD, FRCP, FACP
Professor of Medicine, Dalhousie University
Atlantic Health Sciences Corporation
Saint John, New Brunswick, Canada
Former ACP Governor

Introduction
Healthcare Reform
Healthcare Technology
Access to Drugs
Training and Placement of Physicians
Ethics in Healthcare

I learned more about the American College of Physicians and the American Society of Internal Medicine in the two years while serving as one of its Governors than I probably knew about it during my affiliation as its Fellow between 1970-1998.

No doubt, the eminent status of the College was known to me during the residency training in 1964-65 at the Hartford Hospital, Hartford Connecticut. The impact of its role and influence on the daily practice of medicine was, however, understood at a later date. Being the first postgraduate of East Indian origin in a completely different culture and environment at Hartford was a new experience for me and my comrades around.

It so happens, that the Director of Medical Education at that time was serving the College as its Governor for the Connecticut Chapter. He was a gentle and unpretentious figure. His diligent conduct of hospital and College activities made a lasting impression on my career. That impression was reinforced during the subsequent years by the similar commitment of a few more physicians who had a string of associations with the College. One common thread, which bound these personalities of yesteryears, conveyed a sense to me that the College places great importance on professional dignity, respect for each other and promotion of scholarly activities.

Even though I left the USA in 1968 and began my clinical practice in Canada, the fond memories of the training years in the USA have remained alive. The attributes of the medical profession as it was and how it was being promoted have remained with me. Professionalism and emphasis on ethics and medical education continue to be the main goals of the ACP. Being a part of College leadership, it is eminently important that I promote these goals and ideals.

Proceedings of the College at the Board of Governors meetings epitomize democracy at its best. The grass roots involvement in the decision-making process is, without a doubt, the strength of the College. The leadership also carries the mantle of responsibilities to guide and to be the source of ideas and solutions. The College is open to suggestions, and it is prepared to meet the challenges and changing social-political situations that impact the health of the population at large.

The College is a major medical organization (approximately 120,000 members) to promote and foster academic and professional pursuits by its US membership in the field of Internal Medicine. Internists in other countries, however, also look toward the College for leadership in the field of continuing medical education, scientific breakthroughs, and professional responsibility on issues such as environment and population health. It has been a fulfilling experience for each and everyone one of us who are associated with the College. It has to appear as a global institution to enable international medical graduates, young and old alike, to seek better understanding of medicine in all aspects.

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1) Healthcare Reform

In North America, healthcare reform is probably the single most important challenge facing the policy-makers and perhaps for the candidates seeking political office.

In Canada, there exists a system of universal delivery of healthcare. In the recent past, I note, healthcare has been altered in such a way to control costs as well as to allocate scarce resources, based on a bureaucratic design of a needs-assessed healthcare model. Furthermore, federally-mandated programs, relating to healthcare transfer payments, get downloaded to provincial governments, who in turn are entrusted with the delivery of healthcare, at the provincial level, even in the setting of inadequate funding.

In the United States, healthcare reform takes upon itself a more traditional form of debate…private vs. public access to healthcare. On one hand, a muted approach would follow the status quo, in that there will continue to be both forms of healthcare delivery, regardless of any state intervention. On the other hand, a less-muted approach would allow for a greater emphasis on state-administered healthcare funds.

For ACP members and those Associates in training, there must be endeavors to understand that a united voice from the medical profession must occur for the good of all healthcare. It is a strategy whose time has come. Furthermore, remembering that approximately 40 million US citizens are without healthcare insurance and over 500,000 personal bankruptcies occur each year as a result of citizens being unable to manage the cost of their healthcare. All stakeholders have the fiduciary responsibility of addressing these urgent matters, without delay. It's a very daunting task indeed, but a necessary one.

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2) Healthcare Technology

The bulk of this discussion will focus on the maintenance of patient care from the perspective of diagnostic imaging products in the environment of both private (USA) and the publicly funded hospitals (Canada).

In Canada we are faced with an absolute crisis in the administration of diagnostic imaging healthcare delivery. Equipment in many centers is simply too outdated to continue to be utilized, to provide best possible care.The Canadian government needs to immediately invest approximately 1.5 billion dollars to bring diagnostic imaging modalities up to an acceptable standard.

In the USA, physicians are faced with the dilemma of the managed-care models of resource allocation. For profit-based healthcare delivery, each hospital maintains shareholder accountability and is tightly bound to negotiating contracts with vendors and other purchasing groups, where cost is the sole motivating factor. Drug formularies within these environments take this form of control.

The larger looming crisis exists around the Human Genome project and who will pay from the patents issues and who will profit from this groundbreaking research. Access to these technologies will play on a huge ethical field in the coming years.

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3) Access to Drugs

In recent U.S. coverage of Democratic and Republican debate on the issue of access to drugs, we find both camps trumpeting the aspects of their plan to increase access to drugs for seniors and those in financial need. This is clearly a major issue as we begin to realize the role of the baby boomer population on the public purse- strings and to determine who is to pay for the cost of these medications. Large managed-care organizations play an important role when it comes to formulary inclusion of certain drug products. This has led to direct tendering of patented drugs to certain manufacturers who may possess a drug that could be considered a "me-too" compound and yet still want a share of the market. It is at this stage of the competition game that price rules. This has lead to some alleged price-fixing in some pharmaceutical drug markets, in order to control the influence of managed-care on the availability of certain drugs.

In the Canadian milieu, the system is similar with differences being the absence of a true managed-care environment. However, access to drug products are restricted by provincial health administration. These pharmacare strategies exist for the senior population and those who receive government-sponsored financial aid (welfare). A small percentage of patients who are subsidized with the aid of a drug plan to pay for their drugs invariability face additional restrictions. As a result, certain payers administer a more restrictive list of formulary drugs, limiting physicians’ ability to prescribe alternative drug care for their patients. This is by no means universal.

Perhaps the major and single most vexing question that will face physicians in the coming years will be the access to drugs derived from research based on the human genome project. There are vast unchartered areas of research that will likely produce profound changes in human health. Vaccines, drugs, preventative care are only but a few of the avenues that we will drive down as more information and research come to light about the human genome project. In some respects there may be a "Pandora’s box" as there has been debate even from the office of the President of the United Sates, about how this research must not be utilized for discriminatory polices of insurance companies, job screening and other industries engaged in screening of candidates.

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4) Training and Placement of Physicians

There are several issues that physicians both in specialty medicine as well as in general practice have to come to grips with.

In Canada, a major crisis exists in the available pool of physicians for a reasonable and workable physician-patient ratio. Clearly, recruitment and retention strategies need to employ without delay. One area that needs to be addressed is the number of physician spots allocated to various medical schools. Furthermore, the serious amount of debt they accumulate provides undue duress upon new graduates who may decide to begin practice in under-serviced areas.

One further area of relief that may offer a glimmer of hope is the current debate surrounding the acknowledgement of foreign-trained physicians’ credentials, enabling those doctors trained elsewhere to come to remote areas of Canada as well as the United States to practice.

When I came to New Brunswick 30 years ago, I became its first Nephrologist. As a foreign-trained medical graduate, there were still many obstacles facing me at that time. However, I would like to believe that we have made some progress in that area. Currently I see many of my colleagues that have come to Canada with their spouses, also foreign-trained physicians, who are unable to practice medicine because of limited residency spots available and the need to support their families while one attends to repeating internship/residency. I recall one instance of an older resident that was rotating through our hospital’s internal medicine residency program. As a foreign-trained consultant, he was taking his internal medicine training over again. He now practices in a remote area of another province. Perhaps if he would have been able to practice as a consultant with the understanding that periodic maintenance of competency exams would have been required. This would have re-licensed the physician on a yearly basis.

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5) Ethics in Healthcare

There are many truly difficult areas that new medical graduates must deal with as we go forward in the new millennium. One area of significant debate is the role of the system in palliative/end-of-life care, as well as physician-assisted suicide.

In the state of Oregon, the debate was recently formally broached by an adoption of a law enabling physician-assisted suicide, under certain circumstances. In another state, Maine, which is very close to where I practice, approximately 50 miles away, the issue of physician-assisted suicide was put to a state wide referendum, during recent presidential elections in the Unites States. It is imperative that states and provinces in Canada review this important issue very soon. We can only speculate the amount of human suffering that will occur as the largest cohort of North American citizens approach their retirement years. I am speaking, of course, of the "baby boomers." This cohort will be the subject of much debate when governments, both local and federal, allocate scarce healthcare resources, thus furthering the debate for ethical issues like physician-assisted suicide and in-home care for the ill.

Another important issue for physicians to remain current on is abortion. It would be premature to discuss abortion as simply the act of terminating an unwanted pregnancy. Physicians must come to grips with medicine’s role in the issue of abortion. Although many of us haven chosen other specialties that shield us from such debate, we may find ourselves on hospital ethics committees that may determine the indication for pregnancy termination. Sexual assault, incest and other crimes bring physicians and allied healthcare professionals to the forefront of abortion, as we must struggle to arrive at a consensus as to the appropriateness of abortion, when it is medically, ethically and morally indicated. Lastly, as we look morally into the mirror, we must come to grips with our own religious and spiritual beliefs. In North America, as in other countries, even the act of prescribing an oral contraceptive crosses the barriers of morally/spiritual beliefs of certain physicians. Lastly, I would comment on the availability in the Unites States for the so-called abortion pill, RU-486. In Canada there is a ground swell of support in certain jurisdictions to initiate Canadian clinical trials of this drug, as is the case of British Columbia. Clearly great debate still needs to occur.

As I close this final section, one area of significant interest to North American physicians is our role in performing clinical research. As a Nephrologist, I have had a keen interest in vascular affects of renal disease, specifically hypertension. There are many great research opportunities for physicians to conduct medical research. Ethically, however, research takes on a new stance when newly developed technologies are being investigated in our patients and we must weigh the benefits against the risks. There will be hundreds of new drugs coming onto the market in the coming years and we as physicians must be ready to deal with the ethical issues surrounding them. Their costs, impact on morbidity and mortality, and safety are but a few of these issues.

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Brief bio:

Dr. S. Paul Handa, a graduate of Punjab University, India undertook training In Internal Medicine and Nephrology, and started the first Province (New Brunswick, Canada) wide Nephrology program in 1971. He has served the Canadian Society of Nephrology as a Council member and the Royal College in its regional and national committees. Dr. Handa is a recipient of Order of Merit (New Brunswick) and a Regional award of the Royal College of Physicians of Canada. He is a former Governor for the American College of Physicians Atlantic Provinces Region and was a member of the International Subcommittee. Dr. Handa holds the ranks of Professor of Medicine /Associate Professor of Physiology-Biophysics at Dalhousie University and was Head of Department of Medicine-Affiliate Hospital for 10 years.

This article was prepared for the ACP IMG Web site in 2000.

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