Globalizing medical education

At the 2005 meeting of the Association of American Medical Colleges (AAMC), N. Lynn Eckhert, MD, DrPH, the organization’s outgoing chairperson, delivered an address on the subject of globalization and its impact on the world of academic medicine. In this HMI World Forum, Eckhert, who is director of academic programs at Harvard Medical International, talks about how globalization is taking shape in medical education, and presses for a larger conversation among leaders in academic medicine about the challenges and opportunities inherent in this new era of global health.

HMI WORLD: Why did you choose globalization as the topic for your final address to the AAMC?

ECKHERT: My purpose was to challenge my colleagues in academic medicine to think beyond our geographic borders. Globalization is the defining issue of the century, and I believe it’s crucial for educators and health care leaders in the United States to see what is happening on the world stage, and think about how the give and take of globalization will affect the education of the next generation of physicians.

HMI WORLD: Within a week’s time, PBS aired a new documentary on global health, and the New England Journal of Medicine ran an article on the magnitude of physician movement from developing nations. Is global health suddenly a hot topic, or are we just now noticing it?

ECKHERT: Global health is on center stage. The PBS documentary brought home the compelling argument that global health is our health. The nightly news warns the public that we are but one plane ride away from disaster if the avian flu spreads across the globe. Contaminated foods slip through our borders. The same multi-drug resistant tuberculosis strain can be found in Peru, Boston, and Haiti. Our vulnerability is global.

As Thomas Friedman points out in his book The World is Flat, people have far greater interaction with their counterparts around the world. The multinational role of corporations increases interaction between employees around the globe. Once centered in local offices, more people are on the move for their employment and recreation. Millions of employees live as expatriates in foreign countries both in the industrialized and developing world. They see a wider view of the world and recognize the importance of maintaining the good health of their workforce in the more vulnerable populations. Their exposures may be to different strains of diseases that travel the globe with the itinerant travelers.

Furthermore, retirees no longer relocate in the same community, but find vibrant retirement communities around the world. In this capacity they seek the best health care they can find from competent health care providers working in up-to-date facilities.

In addition the HIV/AIDS epidemic has brought attention to the paucity of care available for the world’s most vulnerable populations and the necessity of developing a more extensive, well-trained workforce to combat the complexities of treating and preventing this disease.

HMI WORLD: Much of the news we hear commonly in the context of global health is grim or, like you say, cautionary. Yet you have a more optimistic view of global health?

ECKHERT: First of all, we should not minimize the fact that the HIV epidemic currently affects nearly 40 million people, nor should we diminish the tragedy of 11 million preventable childhood deaths. Yet health in the developing world is improving; living standards are improving, people are living longer, and chronic diseases are replacing infectious diseases as major causes of mortality and morbidity.

As the populations age in the developing world, the physician shortage will become even more acute. Many of the advances in reducing mortality and morbidity in the developing world are due to public health measures in promoting childhood immunizations, clean water, and sanitation. While physicians played key roles, they were partners in teams of public health experts, engineers, and others who made major differences in health outcomes. Chronic diseases and cancer will more than ever require the leadership and expertise of physicians to help solve these complex problems.

HMI WORLD: Yet studies show significant numbers of physicians from the developing world migrating to industrialized nations.

ECKHERT: Clearly the migration of physicians from the developing world to the industrialized nations affects the health care in the developing nations. Physicians leave their home nations for a variety of social, political economic and educational factors. The robust postgraduate medical education system in the industrialized nations is very attractive to physicians seeking training beyond their undergraduate medical education. Once enrolled in graduate medical education, the likelihood that they will remain in the industrialized nations is very high. The industrialized nations are very dependent on a migratory physician workforce, not only for filling the residency and registrar training positions in the nation’s hospitals, but in joining the permanent physician workforce. Australia, Canada, the United Kingdom, and the United States each have a quarter of their physicians as international medical graduates (IMGs). About 35 percent of New Zealand’s physician workforce is made up of international medical graduates. Some of these physicians are nationals who were unable to matriculate in the medical schools of their own nations, but the majority are foreign physicians trained in foreign medical schools.

There is also a cascade effect whereby physicians leaving for the industrialized nations are replaced by physicians from another developing country. For example, physicians from Zimbabwe seek employment in South Africa, while many South African physicians have migrated to the northern hemisphere or Australia.

HMI WORLD: Are industrialized nations producing sufficient numbers of physicians?

ECKHERT: Projecting the physician workforce has proved a difficult task. In the mid-1980s many of the industrialized nations predicted a physician glut at the turn of the century. The GMENAC Report in the United States indicated that we would have far too many physicians. Part of the dilemma in the U.S. came from physician ratios estimated to match health maintenance organization predictions of models of physician population ratios. Canada and the UK similarly predicted surpluses. Consequently there was no growth in the number of medical school positions offered and in Canada there was even shrinkage. In the past several years Australia, Canada, the United Kingdom, and the United States have all determined that we are not producing enough physicians to meet the needs of increasing and aging populations with more complex diseases. Each of us is now increasing our medical school capacity. The Association of American Medical Colleges, the organization representing the 125 U.S. and 18 Canadian medical schools, suggested an increase of medical school capacity of 15 percent over the next several years.

HMI WORLD: Will that solve the issue of too few physicians?

ECKHERT: Increasing the number of medical schools and the class size of our medical schools will not be sufficient to increase our physician workforce. At the present time we have 140 residency training positions for every 100 graduates of U.S. medical schools. That works out to 24,000 first-year residency positions. Graduates of American allopathic medical schools fill 16,000 of these positions, and 6,100 international medical graduates are offered positions. In the United States we have another group of graduates, the osteopathic physicians, who take 2,600 places. Just increasing the number of U.S. allopathic physicians will likely only displace some of the internationally trained physicians and will not impact the overall number. Thus if we wish to increase the number of physicians in the U.S., we will need to increase the graduate medical education positions available.

HMI WORLD: How can we reconcile the recruitment of international medical graduates to industrialized nations with the impact it has on the resources of less developed countries?

ECKHERT: On the one hand, we pull IMGs into our health care delivery system with our excellent graduate medical education programs and extraordinary opportunities for practice. On the other hand, they are “pushed’ from their own nations by the paucity of postgraduate training positions, insecurity in employment, and social upheaval. Offering physicians an opportunity for professional and personal fulfillment seems like the right thing to do, but draining nations of their best and brightest is the antithesis of promoting equity in health. We need to develop systems in which we all can gain. I foresee graduate training programs developing with the exchange of residents and faculty between nations. There are benefits for us all. Physicians in industrialized nations need to learn more about the provision of care for their more diverse populations, and there are lessons to be learned from the countries of origin of these patients. We are seeing greater cooperation across borders. For example, Yale School of Medicine has promoted international rotations for its primary care medicine residents for the past 25 years. At Harvard Medical School, Brigham and Women’s Hospital has established a residency program in international health.

We need to exam the global production of physicians. In 2002 I published a study of the world’s medical schools, and at that time there were 1,658 medical schools in the world. Africa stood out as a continent with far fewer schools than were needed for their expanding population.

HMI WORLD: The number of medical schools globally has grown by more than 20 percent in recent years, with 366 new schools launched. Little of that growth has occurred in the U.S. In this climate of globalization and physician migration, has there been progress towards creating a universally accepted system for evaluating and accrediting schools internationally?

ECKHERT: The World Federation of Medical Education, under the leadership of Hans Karle, has developed both basic and quality improvement standards. A different course measuring performance outcomes has been charted by the Institute for International Medical Education. Dr. Roy Schwarz is the architect of this system.

With global health on center stage, now is the time to call for a coherent agenda in medical education, one which establishes mutually acceptable international standards, crafts equitable policies of physician exchange, and assures the world of an appropriate mix and distribution of both quality medical schools and graduate medical education programs to meet global health needs. John Hamilton (a noted medical education expert) has articulated this challenge very well, saying, “Do we, in medical education, not owe it to the world that all doctors be trained to the same standard?“

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