Episode Transcript
Interviewer: Welcome to the AAMC. It's a Pathways podcast with the Spencer Fox Eccles School of Medicine. We're talking about some of the challenges in academic medicine and how we can overcome them. Right now, we're going take more of a global view. Dr. Michael Good, who used to be my boss. Didn't you retire? So I pictured golf. I pictured all sorts of activities, but yet you're back. So this must be something that really means a lot to you. What are we going to be talking about today?
Michael Good: I'm at the age where I'm needing a lot more health care, and so I need to make sure there are doctors. We need doctors in the country.
No, you can't deliver health care without the physician workforce. It is a team. We need all the professions. At many AAMC meetings, we have presentations and we talk about the physician workforce in the United States, but you know, 25% of the physician workforce in the United States are internationally trained medical graduates.
So a couple years ago, the AAMC merged with the AAHC, the Association of Academic Health Centers, and a really important point of the AAHC was AAHCI, the Alliance of Academic Health Centers International. And so what that's done is it's given the AAMC an international perspective to many of the issues.
In health, in medical education, research, patient care, and at this meeting it was just great to have colleagues—I'll ask them to introduce themselves in a minute—from around the world giving us some really fascinating perspectives on what's going on with the physician workforce in their countries.
Both the supply and the so-called training pipelines—that's what we're talking about is expanding this conversation about the physician workforce to a global perspective. And as we're hearing and learning kind of what happens in one country affects other countries. But we need doctors. So yes, I'm passionate about it.
Interviewer: All right, let's meet your colleagues here and then let's get into this conversation. So who do we have on the middle mic? What's your name? And tell us your title or what you do.
Sawsawn Abdel-Razig: Thanks. I'm Sawsan Abdel-Razig. I'm the Chief Academic Officer at the Cleveland Clinic in Abu Dhabi, a native New Yorker, but I've been in the UAE for about 18 years. I also practice hospital medicine.
Vishna Devi Nadarajah: My name is Vishna. I'm from Malaysia, and I'm the CEO and Provost of Newcastle University Medicine Malaysia, which is a British university, but it has a branch campus in Kuala Lumpur. I'm a Malaysian, born and bred, lived there, and studied all around the world. It’s just nice to be here.
Interviewer: All right, Dr. Good. I'm going to go ahead and let you lead this conversation. I might jump in in case there needs some clarification, but this is kind of the session after the session. You already had a session where you talked about these issues. Give us a brief overview of what you talked about at the session, and then let's talk about what came after that.
Michael Good: Well, why don't we just do a brief synopsis of what we did at the meeting, and then we will explore some of the things that we didn't have quite enough time for during the session.
Sawsawn Abdel-Razig: Sure. I'll get us started. So I was talking primarily about the United Arab Emirates, a pretty young nation, about 54 years old only, but a rapidly growing nation that's progressive and dynamic with multiple sectors growing within the health care sector and really leading a lot of the change there. So, we were talking specifically about the challenges around an exponential population growth and their health needs. We talked about some of the challenges around the fact that a significant proportion of the population is expatriates coming from outside, which makes our health care providers also expatriates primarily. What it takes to, 1) credential them, 2) privilege them, and 3) have them practicing at a specific world-class standard of care while also keeping them and retaining them with an increasingly globalized health system.
One day, you can be in Abu Dhabi practicing; the next day, you might be in the U.S. through these new pathways that I'm sure we'll touch upon, and another day we might be in Malaysia. So how do we sustain our health services? I'll pass it to Vish now.
Vishna Devi Nadarajah: So I was speaking about Malaysia, which is 60 years old as a country. When we talk about health care, just after independence, our health care system needed doctors, and doctors from South Asia actually came and sort of built our health care. Over the years, we started having more medical schools, producing more doctors, and, in fact, we were doing pretty well.
But in the past four or five years, what we are seeing is that the success is almost causing us some problems. We graduate very good doctors, and they now have opportunities to leave the country. We are finding about 20% just after graduating leave for Singapore, for Australia, or even for the UK.
This is now creating a workforce shortage, and we are quite worried about it. Both the government and medical schools are looking into ways to reduce this workforce shortage because you can't blame the doctors for leaving. You've got to ask, why are they leaving and what can we do to keep them?
Michael Good: I brought the United States perspective. I pointed out that we're fortunate. The AAMC has been tracking physician workforce supply and demand data for a couple of decades, and these data are critical for policy and education programs. I was fascinated by Abu Dhabi, and I think at one point when we started, 1-2% of the whole physician workforce was from the country. You're making progress, but there’s still such a long way to go.
And then Vishna, the way you showed how you're training great doctors and then they’re leaving. I just thought those two dynamics juxtaposed showed one snapshot of how increasingly physicians are moving between countries. We say the U.S., but it's really the United States of America—50 of them—and much of the licensing is regulated or controlled at the state level.
So we're seeing states begin to do things to retain their physician workforce. A lot of the same dynamics that you were sharing are happening between the countries. So one of the things that AAMC and AAHCI do well is they convene people that can report on what's going on in their area, their country, and then we can explore solutions.
One of the things we've been talking about before and after the session is, can we get a data set similar to what we're able to have for the United States from the AAMC. Can we aggregate data and get a better understanding of some of these supply and demand parts of a physician workforce in each country? Ane then begin to explore the migration between countries.
Interviewer: Do you all agree that that's the first step? Do we really need a better understanding, or do you two actually have a pretty good understanding in your particular situations?
Sawsawn Abdel-Razig: That's a great question. I 100% agree—there's definitely data out there. If you look at the World Bank or the OECD or other organizations that look at global workforce migration patterns and characteristics, they do have data. The thing is, that data oftentimes doesn't dig deep enough for us to get a real clear understanding as to what are those pull and push effects that move doctors or nurses from one country to the other.
So yeah, the question was, are we getting enough data? The answer is probably no, not really. Can we take advantage or leverage systems that already have these platforms in place? Probably, and then it's a question of, well, who are the stakeholders? Do we want to engage, and how do we engage them? At the end of the day, the physician workforce is like gold dust. Really. Everyone wants more of them. So how do we also think about how we extend them in different ways? As you know, we talked about artificial intelligence, innovation, and what health care delivery models might look like globally over time. Because we're all looking for the same people.
Vishna Devi Nadarajah: I think one of the things that we may have to look at is, the global data takes a macro view. So even if we shared our databases, we'll still have a macro view maybe about physicians or other health care professions. But we’ve got to have our country or localized data also to take a bit more of the micro view.
So, for example, it's not just physicians. We may have to look at gender for example, or minorities. At which stage of their career are they moving? Those kind of microdata will help us within our national context to solve problems or look into solutions. But the macrodata, which is international, I think will help the transition.
Because we talk about physicians leaving, but some of them come back. Here’s a good example. So in Malaysia, many of them go to the UK for example. There will be a worry for the UK because they train there and at some point they are going to lose those specialists back to Malaysia. So that is at the national level and the international level. Both have different purposes, but we need more of that database decision making and evidence globally.
Interviewer: It could take a long time, right, to get that amount of information? Or no, not really?
Michael Good: Dr. Jaffe, who facilitated our session, gave us an Arthur Ashe quote: “Start with what you have.”
Interviewer: That's where I'd like to see this conversation go. Now, in lieu of that data, what can you do that could have the maximum impact right now?
Michael Good: One is awareness. I wasn't aware of some of these country-specific trends and dynamics of physician supply and demand. So one is awareness. Two is shared learning and shared experiences. As we share our challenges, the collective community will try things. I think we can learn from one another so that when we do have a promising practice, it can be moved to other countries and other areas more quickly..
Sawsawn Abdel-Razig: Those are two great points. Again, there's a universality around some of the common challenges that we have. So the question is, have systems who have dealt with these challenges for longer periods of time dealt with them a little differently? What have they done right? That helps. Knowing what has been tried and tested, what stakeholders need to be at the table, who's actually looking at this, right? Again, there are different viewpoints here, right?
There are the people who are looking at health systems financing from that standpoint. Others are looking at it from an education standpoint. A third person's looking at it from a licensure standpoint. So how do we get the right stakeholders, and what is that form? Is it to have those conversations and bring those people together to start thinking about collectively addressing it?
Vishna Devi Nadarajah: An example that Mike shared about how the residency training positions have limitations to them, but how you looked at partnerships and other sources to fund that.
For me, it was like, OK, in Malaysia we have the same problem. We call it specialty training. It’s so limited that it creates a bottleneck for career progression. But we have the private sector, which benefits most from specialty training programs that are publicly funded.
What can I share? I learn and bring back home that can we now make the. private sector and be more invested in their workforce planning, rather than depending on just a public system. That kind of sharing—it's not just the data, but how they do it. How has a country succeeded or even failed?
Michael Good: That’s a great example. One of the problems I have is I have the brightest idea, the best question, and about 10 minutes after the podcast ends, we work it out together and say, “OK.”
Interviewer: Dr. Good, why don't you go ahead and share your idea that either worked or didn't work?
Michael Good: In the late 1980s and early 1990s, we had a really severe nursing shortage in this country. I was working in the Veterans Health Administration at the time, and I remember we learned that the country of the Philippines was training many more nurses and high-quality nursing professionals. And their country didn't need all of those. So many of our institutions did things to help relocate nurses trained in the Philippines to the United States.
Several other members of the audience for our session were from Latin America and other countries. If we have a surplus of physicians at this point but everybody still needs more physicians, should we be thinking about it differently? I don't know. But how do we get ahead of this? I'm also intrigued by something you said, Sawsan, about other industries that are globalized. The financial world is a great example. We probably need to look there for how they tackle the talent that they need to, to excel in their profession.
What I've learned over the last few days, and then particularly at this panel, is many countries are struggling with a lack of physicians. We're not the only country that's dealing with that. So again, I'm very pleased to have AAHCI spearheading the initial conversation.
Sawsawn Abdel-Razig: Absolutely. Now, I'll piggyback off of something you said. I mean, I think it's interesting to have the awareness around the strategic priorities of different regions and different nations. There are nations out there who are actually supplying nurses as one of their financial drivers in the form of remittances. So what are those nation's actual priorities and are we addressing them? A few weeks ago, I attended this really interesting conference where one of the WHO’s regional directors said that, in their nation, their stance is train them well enough so they can leave but treat them well enough so they stay, which is fantastic, right? It sort of puts it all together.
But I'll give you an answer to your question here around what worked or what didn’t. We identified in the UAE that because there was a primarily expatriate health service workforce, we really needed to bolster locally trained physicians, nurses, and allied health professionals to get the right people to the table. What worked was to think about that value proposition in terms of how that particular stakeholder cared about it.
So it wasn't about the philanthropic, wonderful, philosophical, ideological idea of training doctors. It was, “This is why we need to train, and this is why it matters for you, stakeholder X,” and actually put that in that value proposition. So soon enough. Everyone had the same mental model of what success looked like, and people moved in one direction, uh, to, to increase our residency training programs and our medical schools in the UAE.
That’s an example that I hope people can take.
Vishna Devi Nadarajah: I'm going to give a bit of a different perspective. One of the reasons I findhy doctors are leaving all over the globe Is that. the healthcare system they are in. One of the reason is the work environment, right? The long hours, uh, the lack of career progression.
And the other thing is the toxicity in the work environment, because medicine and health care is a bit hierarchical. So as a trainee or even a medical student, you’re at the bottom of the pecking order. I'm [00:19:00] pushing it back to the educators, right? The medical school deans, those of us who are in the training part, we urge you to take some accountability to create safe learning environments, especially in the clinical environment.
The clinical environment is the most important learning environment, and we’vee got to make the players. Those who engage in that understand what a safe clinical environment is and know their rights. Because I think we have been quite tolerant toward some of these toxic behaviors because we said, ah, let it go.
It's okay. Learn to deal with it. This is going to be the future of your professions.
Interviewer: It's just always the way it's been done.
Vishna Devi Nadarajah: But it's not. It's something where—I can only speak from the context I come from—yes, there have been improvements, but the graduates are telling us now quite explicitly, I don't want this type of life. I don't want this vicious cycle to happen to another person. You think about the investment that has gone into medical school training, it's such a pity that they leave. To me, the way forward is to make sure that the workforce is thriving— not just doing well but actually thriving to create safe clinical living environments. That's where we all become accountable.
Michael Good: I want to add that this meeting and this convening is so important. At one of the Council of Deans meetings, Dr. Julie Barley, who's the dean and executive vice president at Geisinger Commonwealth Medical School, said their system now tracks learner-to-employee conversions—the ratio of learners that become employees. She said that's up there as one of the tracked metrics with the finances and quality metrics. People are leaning in and saying, “OK, what do we need to do? It’s not going to be everybody, but we have made a statement that we want our learners—and particularly our best learners—to become our employees.”
That's how you start to come at the learning environment. Because if the learning environment isn't great, you know you're not going to do well in your learner-to-employee conversions.
Vishna Devi Nadarajah: For me as an educator, if we don't confront the issues, we’re actually colluding. For us to role model it, we’ve got to call out some of those past acceptable behaviors. Professionalism is not bullying. It's not accepting some of this bad behavior. We have to make them see that their career well-being is about looking out for themselves and looking out for others.
Interviewer: Alright, as we wrap this up, one final question. Before we started this conversation, you each had a perspective and a point of view. But now we've shared some ideas. What did you take away from this conversation?
Michael Good: I would like to see AAHCI expand its membership so we can get more perspectives and learn from more of our colleagues around the globe about how this issue is impacting them. Maybe they have some unique solutions that we haven't considered. I'm a big believer in the wisdom of crowds.
Interviewer: That’s a theme that came out in this conversation: it’s so important to share those stories of successes, failures, and struggles.
Sawsawn Abdel-Razig: For me, it’s pretty simple: we are more alike than we are different.
Vishna Devi Nadarajah: I like to say that America is so diverse with the different states that we still want to learn from what's going on here, so keep up the good work. I know there have been funding cuts and a lot of other issues, but the rest of the world is with the health care professions in America.