Foreign medical graduates are not the primary care solution

With immigration reform under hot debate, it’s important to remember that all of us except the Native Americans are foreigners.  It’s what has made our culture so diverse.  People from foreign countries ideally bring the best of their cultures to the US and enrich us all with the diversity of life.  This advantage lessens considerably when those visitors want to enter fields in which understanding of endemic American culture is critical.  So it can be with foreign medical graduates (FMGs).

The New York Times did a piece on FMGs: “Path to United States Practice Is Long Slog to Foreign Doctors.”  Being an FMG has become sort of derogatory.  You tend to see them staffing surgicenters and walk-in clinics and doing primary care in Nebraska.  Sort of like the stereotype of the Mexican immigrant who does work Americans don’t want to do.

Now, I have many friends who are FMGs and they are all fantastic doctors.  They probably were before they were subjected to all three steps of the United States Medical Licensing Examination and a second full residency.  In fact I know they were.  Foreign doctors are caring, professional, knowledgeable, and often smarter than your average american grad.  The reason they work in Nebraska is that, as the NYT article points out, it’s very hard to get credentialed here and many of these talented doctors end up in lower-end residencies in less competitive specialty areas.  They are doing great work in some difficult under-served areas of our country and their own.

There are two problems with foreign doctors practicing in the US.  Number one:  communication.  I did a piece on trust between physicians and patients.  A quick review of research strongly suggests that communication, or a compatible communication style, is one of the most important ingredients in trust between me and you.  Some doctors come from overseas with great English skills, others not so much.  Some come from their countries very “westernized,” some not so much.

Being a great clinician and knowing a lot are part of being a good doctor, but so are the ability to communicate effectively in the language of the patient, and to appreciate the culture and mores the patient brings to her attitudes about health and illness.  This principle goes the other way too.  How many times do western doctors go to third-world countries with the best of intentions and the best of technology, but are unable to make progress because of a profound cultural gap?

The other problem is the “brain-drain” one.  Some foreign doctors trained in the US are desperately needed in their home countries.  While it is a perfect solution to the above paragraph to train a doctor in the US then have him go back to use his language skills and cultural knowledge to bring top-quality medicine to their own country, this doesn’t always happen.  Once people see what we have here it is sometimes hard to leave.

None of this is true in all cases, and I’m sure I’ll get some accusations about racism or bigotry.  I love my FMG friends.  I just don’t think they are a solution to primary care in North Dakota.  One NYT reader commented that maybe there is some way to accredit some overseas programs so that those physicians have an easier transition to the US.  I think that’s a good idea.  Re-thinking the USMLE is another.

The real question is twofold. Why do we  consider all other training programs inadequate?  And why do we think we need to solve the primary care problem with FMGs?  Let’s welcome every doctor who really cares about medicine and people, wherever they are from, support their education and pay them in such a way that young doctors will want to do primary care in North Dakota.

Shirie Leng is an anesthesiologist who blogs at medicine for real.

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  • ninguem

    They are no more likely to go rural than Americans. The only exception is the J-1 waiver, so they go rural for the required number of years……..and then leave.

    They are also no more likely to go into primary care than Americans.

    Actually, their demographics pretty much match Americans, for the obvious reasons, they have the same attractions and dislikes as anyone else.

  • ninguem

    It will become a moot point soon.

    USA medical and osteopathic schools are growing rapidly, but the residency slots are not.

    We’re reaching the point where the number of USA graduates comes close to the number of total residency slots.

    Foreign docs won’t have any place for postgraduate training

  • Ron Smith

    One of the common trends thirty plus years ago if you were an American, but didn’t get accepted in medical school because you didn’t meet qualifications, you could, if you had enough money, get into a foreign medical school, and then come back as a foreign medical school graduate to practice. I commend you that you don’t see this now in a bigotrous way, but I wonder if that pathway has changed little since then?

    Ron Smith, MD
    www (dot) ronsmithmd (dot) com

    • ninguem

      It continues. Heck, Ross University is run by de Vry now.

      The problem will be postgraduate training. The mainland USA schools are growing in size and number, but the postgraduate training slots are not.

      Priority will have to go to USA grads. Nothing against the foreign docs, either USA nationals or foreign nationals. But imagine if substantial numbers of Americans, in American schools, with a good work ethic and good academic preparation, unable to get postgraduate training because positions went to foreign nationals?

      There would be open revolt. Students that invested hundreds of thousands of dollars in their education, to end up unemployed because absolutely no residency slots are available.

      Word would get out, and the schools that could not place their graduates, would get no applicants the following year.

      So those slots will have to go to USA graduates, with no disrespect to the foreign docs, and the whole thing would become a moot point.

      The only possibilities are, maybe, funding opens up for more postgraduate training positions, which I doubt, or maybe the system would become open to those trained in comparable systems, such as the Royal College system.

    • Suzi Q 38

      I agree. Aren’t there medical school programs for Americans in Mexico and Granada?

      • ninguem

        Indeed there are. Heck, Ross University is owned by deVry.

        The sticking point will be residency (postgraduate) positions. The number is not growing, there’s no funding.

        The number of graduates of the MD and DO programs within the USA is growing substantially. With all due respect to the foreign graduates, the postgraduate programs are going to give priority to their own students, same as would happen in any other country.

        So the effect will be to squeeze out the foreign docs. Next on the chopping block could be…..I say COULD……would be the programs outside the USA, that cater to Americans. Ross University, St. George, etc.

        Thing is, from what I read, those schools have seen the handwriting on the wall. They kick back money to certain USA hospitals to keep slots open for their graduates. If inadequate government funding and/or hospital resources, they get money from those schools, really the student tuition.

        Not saying there’s anything wrong with that, they’re doing what they need to do. If they couldn’t place their graduates in USA postgraduate programs, no one would be crazy enough to pony up the big buck tuition they charge.

  • amohtap

    If foreigners want to practice here, they have to pass the USMLEs and get a residency, just like our own graduates.

    The US, by far, is the most lenient country in the world in allowing foreign doctors to practice in America. Practicing medicine from a foreign degree is a privilege the US has extended, not a right nor a guarantee. In most other countries, if you have a foreign degree, tough luck; stand in line for the next 5-15 years while you wait for a residency spot to open up and on top of that, you might never leave training because of your foreign degree. At least the US has a straightforward (albeit competitive) system to allow you to practice independently.

    And let’s not mince words here. Foreign doctors come to America because they want that big pay day that American medicine can provide. They have no true interest in helping the underserved, the rural areas, the poor. They want to cash in with their (supposed) expertise. That’s fine; that’s part of the American dream and American culture to be rewarded financially for one’s talents. However, they have to play by the same rules as everyone else.

    Just like I can’t go to Belgium and practice medicine over there with no restrictions, even though I may have completed training over here in America, so do foreign trained physicians wanting to practice in America have to complete our guidelines and requirements.

  • lovemygrandchildskylar

    my sister-in-law come from South Korea to Canada..then came into Illinois to get her medical degree in OB/GYN…she meet my brother there, he graduated..they both passed their boards in California…she couldn’t go back to Canada when her dad got sick because of possible problems at the border…but she had a job as an OB/GYN at the time in a mid size medical clinic in California at the time…she didn’t have any trouble getting a “slot” in medical school…not sure where the problem comes in…one of the major teaching hospitals here has a wing bought and paid for by some chinese guy..all the attendings are chinese..most of the time you can’t understand what they are saying.but they dont seem to have a problem with the fact that they aren’t understood..they understand each other..guess that’s all that matters right?…

  • traumadoc

    this problem will continue until one can buy a license! i am a US born citizen (60YRS old). i gave up on ECFMG and all the other bull.
    i went to med school in rome, italy. did a residency in italy and switzerland in pediatric surgery. i now work in italy, france, germany. i would never put up with the american politics again.
    tell the IMG’s that it is a lost cause. goo home and help your own kind——–this is wise advice.