Internal Medicine: Global Perspectives
Aru Sudoyo, MD, PhD, FACP
Located in Southeast Asia and Oceania, Indonesia is the world’s fourth most populous country, with a population of about 237 million, right behind the U.S., which ranks third with a little over 300 million. The health care system in Indonesia has its unique challenges. Its 17,508 islands often make communication and transportation problematic; compounding matters is the 20 percent of the population living below the poverty line, and the allocation of only fifteen percent of the National Budget toward health care. Compared to the U.S., which has approximately 215,000 active internists, Indonesia has just 1,764 to treat a population nearly the same size. At the same time, while the number of medical students pursuing internal medicine has dwindled in the U.S., students in Indonesia can’t get enough of it and are flocking to it in droves.
In our April profile, Dr. Aru Sudoyo, President of the Indonesian Society of Internal Medicine, discusses what it is like to be an internist in Indonesia, how the work of the Indonesian Society of Internal Medicine is making progress for the profession, and how the spirit of the Indonesian people keeps things afloat.
Indonesia At A Glance
- Total population: 237 million
- Number of internists: 1,764
- Physician-to-patient ratio: Anywhere from 1 to 25 to 1 to 100
- Life expectancy for men: 68
Life expectancy for women: 73
What is the role of "internist" in Indonesia? What do patients expect from an internist?
Patients in Indonesia expect their internists to be very knowledgeable and to make accurate diagnoses. The majority of patients in Indonesia have faith in their doctors, but an increasingly large number of well-educated patients are seeking more explanation regarding their illnesses.
Are young physicians pursuing internal medicine?
Yes. In fact, we have to turn away 75 percent of candidates every semester (trainee recruitment is performed every semester). Internal medicine is still one of the most popular medical specialties, probably because of the perception that it is not as physically demanding as surgery, yet similarly respected and regarded in the community. The main barrier is that training centers are not able to accept and handle as many trainees as they would like.
What inspired you to become a physician?
Actually it was not so much inspiration as it was pragmatism and the result of realizing my own strengths. As a young doctor in a remote island in the eastern part of Indonesia, I had to perform almost everything including surgery (Caesarean section and hemicolectomy, among others). Performing those surgeries gave me the opportunity to do some self-assessment. The first thing I considered was whether or not I could be a good surgeon. I wear glasses, and I found that after several hours of surgery, my eyes would strain for me to cut the surgical thread. Further soul-searching revealed that my strength was handling and analyzing clinical data, or as I like to call it, solving mysteries. I also enjoyed and was good at communicating with people. So my choice was internal medicine. Or rather, internal medicine chose me. And I have not regretted it ever since.
What are your responsabilities as president of an IM society? What are your other professional activities?
The responsibilities as president of my Society largely deal with contending with changes and threats from both within and outside the organization. For example, internists unfortunately are forced to compete for hospital services and facilities with a group of cardiologists and pulmonologists who completed their training without the two years of internal medicine. My responsibility is to hold the fabric of general internal medicine together and to instill the sense of belonging necessary to uphold that unity in the face of threats.
There are responsibilities within the organization as well. An example of this is our recertification process. Several years ago, a National Medical Council was formed, reporting directly to the President of Indonesia. One of its first directives was to require every doctor to undergo recertification every five years. My responsibility, and challenge, is to set up a system of CME (or CPD) that accesses the nearly 2,000 internists spread throughout Indonesia with less-than-optimal communication and transportation.
My other professional activities include lecturing Internal Medicine at the University of Indonesia, and working as a consultant in hematology/medical oncology.
What have you accomplished during your tenure or what would you like to accomplish?
I inherited an organization that was operating more as a “club.” Partially as the result of changes outside the organization that have to be met, in my tenure we have made it into a more professional organization that is ready to deal with challenges. As a result, I think our members from 33 chapters throughout the country feel more unified and have a stronger sense of purpose.
What have you found to be the most challenging part of leadership? The most rewarding?
The first challenge was in the very beginning of my tenure in July 2007. We were the youngest team ever, with no professors at the helm (they were only “advisors”). By the end of one year, however, we silenced our critics by turning the organization around from a lumbering sleepy giant to a dynamic organization to be reckoned with. That was rewarding.
A more ongoing challenge has been reminding hospital administrators that internists can handle heart problems. Our minister of health, who is a non-internist cardiologist and has power over almost all government hospitals, is systematically changing the rules. In some hospitals, internists are barred from seeing heart patients in the ER and consultations have to be given to the cardiologists.
In addition to fighting for the rights of general internists to handle these cardiology and pulmonology patients, we are under attack for the emergence of a new specialty—the internist-cardiologist. These physicians are consultants, full internists continuing their training for three more years. They are under attack by the non-internist cardiologists who claim that they are “illegal.” They have the backing from the minister of health, but fortunately the minister of education is backing us.
Is access to electronic information or products influencing what patients want from their doctors in Indonesia?
Yes. We are seeing a difference in large cities, and for the better. Patients are starting to bring literature with them to their physicians that they have downloaded from the web, and they are asking more questions.
Are there other countries you admire for their health care systems and if so, what can you learn from them? What could other countries learn from yours?
It would be unrealistic to aspire to the American system, however, closer to home I admire the health care system of Malaysia. The government takes good care of their doctors and consequently their patients. Our situation and problems are somewhat unique, with Indonesia being as large as the United States, but with so much water in between our seventeen thousand islands. Twenty percent of the population is below the poverty line, and only fifteen percent of the National Budget is allocated for health care. We have only 1,764 internists. So what other countries can learn from us is perhaps the resilience of our people, and how they manage to get by with a close knit, extended family system.
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