The physicians to solve the doctor shortage are already here

Catherine Rampell recently wrote up an often-overlooked aspect to the doctor shortage debate:

Thousands of foreign-trained immigrant physicians are living in the United States with lifesaving skills that are going unused because they stumbled over one of the many hurdles in the path toward becoming a licensed doctor here.

The United States already faces a shortage of physicians in many parts of the country, especially in specialties where foreign-trained physicians are most likely to practice, like primary care…

The new health care law only modestly increases the supply of homegrown primary care doctors, not nearly enough to account for the shortfall, and even that tiny bump is still a few years away because it takes so long to train new doctors. Immigrant advocates and some economists point out that the medical labor force could grow much faster if the country tapped the underused skills of the foreign-trained physicians who are already here but are not allowed to practice.

It’s a great article, one that you should read in full if you’re skeptical about the magnitude of the issue. And the international medical graduate (IMG) issue as a whole is essential to understanding what our “doctor shortage” is and how to fix it.

First things first: the whole notion of a doctor shortage might seem implausible to many of us. Yes, it can take time to get a checkup with the PCP, but in many metropolitan areas there are actually plenty of doctors (even in primary care). It turns out the doctor shortage is primarily an issue of geography: it’s not so much how many doctors we have, as where they set up shop. Many proposals to increase the doctor supply ignore this fact, and drive more doctors to well-stocked urban areas. Why? The same reasons anyone would rather live next to an art museum than a ball-of-twine museum—desirable metropolitan areas are, well, more desirable. But according to the AMA, IMGs disproportionately practice in those areas underserved by domestic graduates:

Fully 25% of physicians practicing in the U.S. and 27% of residents and fellows are IMGs. These physicians overwhelmingly are the men and women who provide care in underserved and rural areas and to populations that might not otherwise have access to health care. Our numbers tell us that IMGs tend to practice in areas that have a ratio of fewer than 120 physicians for every 100,000 people and a high percentage of elderly and minority patients. We need them. Badly.

Second, the international docs in this article are not all back in their home countries, chomping at the bit to come stateside. They’re right here in the US, under our noses, languishing in technical roles that waste the immense training they acquired abroad. In other words, the “brain drain” critics invoke has already happened—they’ve already left their home countries—but under the status quo, their medical training is helping no one. By letting them practice in the US, where they have already relocated (for one reason or another), at least their skills are going to use somewhere.

So what’s stopping them from practice? As Rampell points out, there’s a slew of hurdles, but one outweighs all the rest:

The process usually starts with an application to a private nonprofit organization that verifies medical school transcripts and diplomas. Among other requirements, foreign doctors must prove they speak English; pass three separate steps of the United States Medical Licensing Examination; get American recommendation letters, usually obtained after volunteering or working in a hospital, clinic or research organization; and be permanent residents or receive a work visa (which often requires them to return to their home country after their training).

The biggest challenge is that an immigrant physician must win one of the coveted slots in America’s medical residency system, the step that seems to be the tightest bottleneck.

The biggest irony is, this is the same exact bottleneck preventing domestic med students from addressing our doctor shortage. Six percent of American grads still don’t make it into residency programs. Despite that, American med schools are popping up left and right; overall enrollment is set to increase 30% by 2016. But without more residency spots, we’re most likely going to have more wasted medical degrees—both American and international. Most alarming of all is that President Obama has actually tried to decrease residency funding further—by 7-10% over the next decade (since residencies are funded primarily through Medicare)t. There are immigration and credentialing hurdles to IMG practice that are far beyond my expertise, but protecting the residency spots we have is a no-brainer.

Finally, there is no good reason to believe IMGs are worse doctors. The ones who make it to the US are the best of the best in their home countries, and research shows they may even outperform those with American degrees clinically—mortality rates for heart failure and heart attacks were actually better in the patients of IMGs. I’d also point out our rich, diverse population of immigrant patients. If you believe we need more black and Hispanic doctors because they provide more culturally competent care to black and Hispanic patients, I challenge you to argue the same isn’t true for patients who are Chinese or Russian or Brazilian. The doctors are here. Let them do their job.

Karan Chhabra is a medical student who blogs at Project Millenial. He can be reached on Twitter @KRChhabra.

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  • openyourmind

    Come to the United States, don’t do a residency, start practicing. Are you fricking joking? While American doctors languish away in their residency? Get lost! I’ll take a PA or NP over one of you. They are the ones in the rural areas.

    • Karan

      The solution I proposed was to open more residency spots. The implication (however subtle) was that domestic and international graduates should fill those residency spots.

      • Guest

        Subtlety is lost on our newest doctor hating poster.

      • Guest

        As long as all doctors, both American and foreign, are held to the same standards of education, training and assessment, I see no problem with that. It shouldn’t have to come down to an “us or them” stand-off. It should be, “all of us, plus more of them”. That would serve both our medical community and our patient community well.

      • Margaret Houlehan

        Good luck with that one. The AMA has a vested interest in keeping these slots to a minimum.

        • Mengles

          The AMA doesn’t fund residency spots you twit – the federal govt. does.

          • ninguem

            She can’t be reached with facts Mengles, it’s useless.

            Don’t feed the trolls I say.

    • Close Call

      False. NP’s and PA’s are trending away from primary care AND rural areas. It’s a common misconception they are preferentially choosing rural areas or primary care.

      I’d take a foreign trained doctor with 30 years experience over a fresh, unsupervised NP w/ just 2000 hours in training any day.

      • Margaret Houlehan

        Really? The reason PAs and NPs are trending away from primary care and rural areas is because they are chained to the supervising physician requirement. Well, it is no secret MD/Do s are not going to these areas.

        • Suzi Q 38

          This is a good example of why they are sorely needed.

        • Mengles

          Wrong. The reason that PAs and NPs are trending away from Primary Care and rural areas is bc they TOO want to go for specialties.

          • ninguem

            Sorry Margaret, Mengles is right. The PA’s and NP’s have the exact same motivations as physicians, and they are drawn to the specialties for the same reason physicians are drawn to specialties.

            To the extent that nurses are more often female than male, to the extent that NP’s are more female than male, women are even less motivated to move to a rural area than men.

          • Margaret Houlehan

            Wrong. If NPS and PAs did not have the antiquated SP requirement, perhaps they would be able to work more extensively in rural areas. Just a thought.

          • ninguem

            Wrong yourself.

            NP’s practice independently in my state, urban or rural. That there is a shortage of NP’s in rural areas is not because of supervision rules. There are, in fact, independent NP clinics, three of them that I know of, in my county.

            Don’t know about PA’s, nor do I know the rules in your state.

            To get rural critical access designation, a clinic has to hire NP’s. There are actually incentives in the system to attract rural NP’s. The reason I didn’t go with a rural critical access designation was I didn’t want to hire a NP, and found out from the regs, confirmed by the state medical school office of rural health, that it was required for the designation.

            Come on down to my rural county, you can set up independently tomorrow. No need for physician supervision. If you’re a NP, I don’t know PA rules.

            But hey, what do I know, I just practice in a rural area, I looked into getting critical access designation myself, get the reports from the medical school office of rural health

          • Cyndee Malowitz

            Are you aware that private insurance companies reimburse us 50% less than physicians? There were a lot of PA and NP owned primary care clinics in rural areas of Oregon, until the insurance companies dropped reimbursements. The PA/NPs who owned clinics simply couldn’t afford their overhead and closed their doors, leaving many people without healthcare. Fortunately, the legislators in Oregon passed a law making that illegal. Hopefully, we’ll see those changes in Texas at the next legislative session.

            BTW – I own a clinic that treats medically underserved populations.

          • openyourmind

            I looked your clinic up. Incredible. Everyone should be celebrating what you do.

          • openyourmind

            Why would anyone give a thumbs down to a clinic who is providing primary care services to underserved populations????? What kind of worthless idiot are you? Better the people rot and die in pain in the street than receive high quality healthcare from someone other than a doctor. The responses and “thumbs down” on this blog tell more to us patients and others reading than anything else. This blog is a true testament to the pulse of SOME doctors in this country. Karma is a bitch.

          • Suzi Q 38

            Two words:
            Jealousy and envy

          • Suzi Q 38

            Thank you, Cyndee.
            You are exactly the type of business I am talking about. You serve people that need you.

          • Jason Simpson

            Why would i want to pay the same to see a nurse when i can see a real doctor instead?

          • Guest

            “Are you aware that private insurance companies reimburse us 50% less than physicians?”

            But with all due respect, you’re NOT physicians. What next, will pharmacy assistants who tell me what brand of headache pill to buy want to be compensated at M.D. rates?

            Co-pilots don’t get paid as much as pilots, dental hygienists don’t get paid as much as orthodontists, kindergarten teachers don’t get paid as much as tenured university professors. Why should nurses get paid the same as doctors?

          • Suzi Q 38

            When my doctors confused about what medication to give me I asked my Pharm.D.

          • Guest

            I want to see every single insurance company reimburse physicians 50% less for the patients treated by their NP or PA. You’ll be screaming equal pay for equal work faster than a NY second.

          • Cyndee Malowitz

            So you’re saying that physicians should get reimbursed 50% less for those visits treated by their NP/PA? When I worked for physicians they were reimbursed the same rate for my services as they were their own. However, they never saw the patient, never reviewed a chart and had never even met a lot of my patients.

          • buzzkillerjsmith

            The reason that NPs and PAs are trending away is that independent rural practice is about as enjoyable as a daily lumbar puncture. Urban and suburban primary care is no bowl of cherries either. Much, much better to work in a derm practice or ortho or endocrine or rheum or you name it.

            NPs can practice independently here in WA but most want to work in groups with us MDs. I for one am happy to have them around.

          • DrPatient

            They shouldn’t work independently anyways, anywhere. We need actual PHYSICIANS to meet the need for PHYSICIANS. It is a rule for a reason. NPs and PAs do not even come close to the same level of diagnostic skill of a physician, especially in general medicine. You are trying to basically say we need to meet the demand for more fresh water with petroleum…they do different things.

        • Guest

          LOL, wrong. They are trending away because of the poor pay and crushing bureaucracy, just like physicians.

    • Margaret Houlehan

      Thank you. When you consider most doctors trained in Europe or other countries go right from high school to a Bachelor of medical studies, how superior are they really to PAs/NPs?

      • Jack

        Seriously? In Australia, that’s 6 years of medical school (undergrad, yes, but medical school) and a minimum of 3 years of hospital practice and 3 years of general practice training to become a qualified family practitioner. 12 years of medical training or a 2 year PA program. Yep, definitely equivalent, right there…

        • Margaret Houlehan

          Jack: Only we are not talking about Australia. The insecurity some physicians display is astounding. Fragile egos, to be sure.

          • Jack

            Hot Lips, you’re the one who mentioned other countries :-) If you prefer, we could stick with England’s 6 year program plus 3 years hospital (minimum) and 3 years of general practice, or perhaps Germany’s 6, 3 and 3, or France, Finland…. pretty much any developed nation you care to name.

            It’s certainly true that some physicians are frighteningly insecure, not to mention arrogant… if only those qualities were exclusively limited to physicians!

          • ninguem

            Assuming it’s lifted from “M.A.S.H.”, it’s Margaret Moulihan

          • Margaret Houlehan

            Ha ha. You are so funny. Not. At least I have the guts to post my real name, unlike many here. LOL

          • ninguem

            Fine, it’s your real name. You still mouth off about European medical education without the slightest idea what you’re talking about.

            You don’t know how the other systems work, they train doctors same as we do, that “bachelor’s” takes six, seven, eight years, same as the USA. We used to have bachelor of medicine degrees in the USA, it was changed to a doctorate. The name is irrelevant, what counts is the time required for training is the same.

            And we have direct from high school to medical programs in the USA, same as Europe.

          • Suzi Q 38

            True. I don’t even post my real name.

          • Margaret Houlehan

            Thank you for the honesty. It is quite refreshing around here.

          • Suzi Q 38

            Thanks.

          • Suzi Q 38

            You have more guts than me…Suzi is not my real name, but at least I am not “Guest.”
            Those people are “trolls.”

          • Margaret Houlehan

            True. But it seems like arrogance is prevalent to physicians…..the insecure ones.

          • Margaret Houlehan

            I guess you would know about that, physician or not, Jackie.

          • Margaret Houlehan

            Jack: points well taken. Physician: superior. Non-physician: inferior. Got it. The gratuitous reference to my name, not so much. Sadly, I am one of the few here with the fortitude to post my real name. And I truly do apologize. I did not realize physicians’ egos were so delicate. I will bow to thee, Aqua Buddha! LOL

          • Guest

            No one except you is making this a petty attack of physicians versus NP/PAs. It was explained to you why they don’t do as much primary care or set up in rural areas. It was explained to you how extensive physician training is after YOU posted your misconception about reduced training in other countries.

            I do not post using my real name to protect my family from the wackos on the internet. This is a public, unmoderated forum; who knows who comes here. I’ve got nothing to prove by using my real name.

            Some physicians may have delicate egos. However, when points are clarified for you you are the one who becomes defensive and attacks physicians for having “delicate egos.” Here’s a mirror; take a look at a really fragile ego.

          • Suzi Q 38

            At least pick a consistent fake name.
            By using “Guest,” we sometimes confuse you with other trolls.

          • Jack

            Margaret, posting with your real name shows something, but it’s not bravery. This is the Internet, not your local coffee shop. I find it interesting that you’ve assumed (incorrectly) that I’m a physician – why are you so interested in making personal attacks against them? Like ninguem, I found it ridiculous that you were trying to compare two obviously different educations. I assumed it must be because you had no real knowledge of overseas medical education and obviously hadn’t bothered to do even the most cursory search for information – a 10 second read of Wikipedia would have saved you from your blunder. I’m curious – are you posting with your real name because you troll in real life, or are you only this stubbornly wrong online?

          • Margaret Houlehan

            Jack, I do apologize. Obviously, this is a very polarizing issue for many different parties. To answer your question, yes, I can be an opinionated PIA in real life as well. I do need to temper my responses. I appreciate your input.

          • Jack

            Fair enough, and thanks for that – we can all be opinionated ‘joys’ at times, I know I’ve done my share! As you say, it’s a polarizing issue – I just think that we can help de-polarize it a bit by ensuring that the information we share is accurate and objectively portrayed. For what it’s worth, I’d respond the same way to a commenter who compared a PA’s education to an EMT’s or home health aide’s. PA’s and NP’s, when appropriately trained, are true midlevel practitioners and shouldn’t be directly compared to physicians or entry-level providers like EMTs. They can be under- or over-qualified for their jobs depending on their backgrounds and personal qualities, just like anyone else.

      • Mengles

        You do know that those programs in Europe are 6 years right?

        • ninguem

          Six years after an academic high-school degree, like the British “A-level” or the German “Abitur” etc., which is more like a USA Associate’s degree.

      • Guest

        I can’t believe that someone is insinuating that the standards for European, British, Australian, etc doctors is no higher than the standard to become a nurse in the USA.

        Dear Nurse, why don’t you take your American nursing degree, and demand to practice as a Doctor in the UK or France? Hahahahaha.

    • Margaret Houlehan

      openyourmind, I appreciate your posts. The docs here have very fragile egos, but you make some solid points.

      • DrPatient

        I have yet to find anyone who matches the arrogance of the average NP these days.

    • Cyndee Malowitz

      I heard some physicians complain that foreign educated physicians ruined their chances of negotiating higher reimbursements with insurance companies. It was an interesting conversation and no one mentioned anything about competency.

      • Suzi Q 38

        It is difficult to argue competency when many of these doctors would do a good job. Many are very skilled.
        Some have to perform surgery and other medical treatments under extremely difficult conditions (war).

    • namjemo

      IMgs who have completed their residencies in their home countries!!

  • Suzi Q 38

    My PCP is a board certified Internal Medicine doctor from Korea.
    His English is very good.
    He has an accent, but so what.
    I learned that at many medical schools in other countries it is a requirement that the physicians speak at least some English…is this true?

    If so, I would not hesitate to ask a foreign born, english speaking physician with over 20 years of experience to treat me after a residency stint in the U.S. I trust that there would also be a written and oral exam at some point, too.

    Why have them be underutilized as store cashiers, taxi drivers, or even hospital receptionists when we need them???

    I have seen this over and over again at my adult school. I teach the English language to adult students from other countries. They are scared, grateful, kind, and hopeful for their future, despite the fact that many have left everything behind in their counties to start all over again here. Others are quite wealthy, and go back and forth from their country to the U.S. Everyone has an interesting story to tell.

    Some are underutilized physicians, lawyers, nurses and others who are from war-torn countries that come here so that they won’t get shot at or killed.

    I had one banker that was here because his brother and father were killed in the same week for being Catholic in a Muslim country. He is now working at the local car wash at the age of 40.

    There are others that were vocal in their countries about human rights, and were jailed. There are so many like this from China. If they were to go back to their country, they would be jailed and/or physically punished. Their government had put pressures on their employers to fire these dissidents. Their children were barred from attending schools. Some managed to get out and are professionals, ready to work if necessary.

    They speak several languages.
    If I needed a new doctor (if mine retires or dies), I would not hesitate to enlist the help of a foreign doctor if there is a severe shortage.

    My daughter is studying to be an NP.
    I think that there will be enough work for all.

    Good story, Dr. Chabra.
    More residency spots are a good solution.

    • Margaret Houlehan

      Amen. Why the turf wars? Only insecure people indulge in that. There are more than enough sick patients out there. LEt’s work together instead of against one another.

      • Suzi Q 38

        Insecurity and fear.
        Totally understandable.

        • Margaret Houlehan

          I’ll say it again. There are more than enough patients out there. Md/ Dos are NOT going into primary care. Nature does abhore a vacuum. Someone will fill it.

  • Guest

    / / / / / / / / / /

    If you believe we need more black and Hispanic doctors because they provide more culturally competent care to black and Hispanic patients, I challenge you to argue the same isn’t true for patients who are Chinese or Russian or Brazilian.

    / / / / / / / / / /

    …or American?

    I mean, if it’s cool for every other race and nationality to demand same-race and same-nationality doctors on “cultural” grounds, it’s all right for white Americans to demand white American doctors on “cultural” grounds, right? Hmmmm. The wing nuts will love that one!

    I wouldn’t have thought that encouraging racism and xenophobia would have been a desirable thing for us to do in this “Great American Melting Pot”. Balkanisation! Maybe people of all races and nationalities should be expected to look beyond race and nationality and see doctors (no matter their hue, no matter their country of origin) as doctors. Discrimination and racism should never be acceptable.

    • Margaret Houlehan

      Well, by his name, we can tell what side this medical student’s bread is buttered on. Sorry, but truth is truth.

      • Suzi Q 38

        White Americans demanding white doctors??
        There was a time in the not to distant past where this was a reality. It may be a present reality for many. They just don’t advertise it. It is all who each person feels most comfortable with and prefers.

        Chinese patients wanting Chinese doctors? I had relatives that did not demand Chinese doctors, but they preferred such.
        Just as my MIL who was Italian American, preferred doctors of Italian decent.

        I am not sure if the preference was because of cultural preferences or language considerations. Maybe it was a little of both.

        It is difficult to get “Popo,” who speaks Cantonese, to explain her chest pain to a physician that speaks only English.

        If I were living in Barcelona, I would try my best to find a physician that spoke English, rather than Catalan.

        This is the United States. Almost all physicians speak English. You can bet though, the ones that speak several languages do so every day.

        This means that there are patients that like explaining what ails them, due to its complex nature, in their native language.

    • Suzi Q 38

      White Americans demanding white doctors??
      There was a time in the not to distant past where this was a reality. I am talking as late as the 70′s and early 80′s. Unfortunately, it may be a present reality for many. They just don’t advertise it. It is all who each person feels most comfortable with and prefers.

      Chinese patients wanting Chinese doctors? I had relatives that did not demand Chinese doctors, but they preferred such. Believe me, there are plenty on the island of Oahu.

      My MIL who was Italian American, preferred doctors of Italian decent. Does that make her a racist? Not sure.
      Maybe she was from Italy, so an Italian American physician was who she preferred and enlisted to care for her and her family.

      I am not sure if the preference was because of cultural preferences or language considerations. Maybe it was a little of both.

      It is difficult to get “Popo,” who speaks Cantonese, to explain her chest pain to a physician that speaks only English. It would be just too hard, as I don’t speak Cantonese as well as my grandmother did. Truth be told, I speak only English and Spanish. If “POPO” insisted on a PCP who spoke both English and Cantonese, she has every right to request such a physician. I am sure that they exist.

      If I were living in Barcelona, I would try my best to find a physician that spoke English, rather than Catalan.

      This is the United States. Almost all physicians speak English. You can bet though, the ones that speak several languages do so every day.

      This means that there are patients that like explaining what ails them, due to its complex nature, in their native language.

      I speak English, so I just try to find the best physician I can to treat me. H/she can be from Slovakia for all I care. Just because I am of a certain race does not limit my selection of my physician to that race.

      On the other hand, I don’t have any English language difficulties.

      • querywoman

        Many doctors, including those for whom English is their first language, have significant difficulties comprehending the English language.

        • Suzi Q 38

          I never thought of that.

          • querywoman

            Sometimes the truth is right in front of us, and we don’t see it. As a professional patient and a former pharmacy rep, need I say more to you?
            Kudos! So far, you and I have received 1 dislike each here!

          • Suzi Q 38

            I just gave you the “ups” sign!
            I just discovered this!
            How fun.

          • querywoman

            I upped you again too! Some mystery troll shore got my drift!
            You can look all through this site, and you will see many fine examples of doctors and alleged doctors going off on tangents that have nothing to do with the comment to which they are responding.
            Next time I have a problem in an office, maybe I’ll switch to my choppy, passable Spanish.

            Do doctors still learn Latin? I could compose a repertoire of snappy comebacks to stupid comments that are readily available in translation on the net from Classical Latin.
            Et tu, Brute!
            Veni, vidi, vici!

          • Suzi Q 38

            I upped you again.
            Just like physician evaluations on the Internet, I can give my friend or myself a positive “star.”

          • Suzi Q 38

            I hope to someday resign from my “professional patient” job. I don’t want it to be by death, either.
            I want to quietly get well……and go back to my formerly blissful life back in 2011.

          • querywoman

            Cyndee Malowitz

      • Tran

        What foreign language do Blacks speak, that they can only be best cared for by Black doctors? This is ridiculous. If someone proposed that we needed more White doctors, to care for White patients, they would of course be called racist, and no one would think it acceptable. This is America in 2013, not 1953.

        • Suzi Q 38

          It certainly sounds ridiculous, but blacks speak mainly English and a variety of other languages.

          I don’t have an African American physician, but I am open to going to one because h/she speaks English as do I.
          If my grandmother speaks Cantonese and I have the choice of two doctors, one of which does not speak Cantonese, you can bet that I will go for the doctor that speaks both English and Cantonese, no matter what color.

          White doctors caring for White patients was quite customary in the 40′s 50′s, 60′s, and yes, even 70′s. I even saw it a lesser amount of this during the early 80′s.

          It is what it is.

          Thankfully, we do not see this now.

        • Suzi Q 38

          I wouldn’t know, but Ninguem does.
          Ask him.

    • Tran

      Yes, it is a strange and uncomfortable premise that “we need more black and Hispanic doctors because they provide more culturally competent care to black and Hispanic patients”.

      Blacks must stick with Blacks, Hispanics must stick with Hispanics, presumably Whites must stick with Whites, because everyone is best cared for by “their own kind”?

      In what world is it acceptable to propose such a thing??!!

      • Suzi Q 38

        it may be geographical.

      • Mika

        I think they were pretty big on that sort of thing in South Africa, under Apartheid.

      • Oline Wright

        when I still lived in the US It didn’t matter to me where my doctor came from as long as I could understand him/her and we had a good doctor patient rapport (meaning the doctor actually listened to what I was saying instead of deciding they knew what was wrong without listening to me)
        .

    • Shirie Leng, MD

      Wow guys, lay off. I think it’s absolutely true that some people are more comfortable with someone of their own race and/or gender, and if so they should seek out a doctor that is more like them. It’s not discrimination or racism. It’s a matter of understanding and communication, which is what you want most from your doctor.

  • morebuzzkills

    Here’s the three sentence summary in case you don’t care to read the whole article:

    Our government makes dichotomous decisions. Government wants to expand health care and increase physician supply. They increase medical school enrollment, but then cut the residency funding which is necessary to becoming a physician.

    The real tragedy of the story is that this decision (as well as numerous others) made it past the radar of an increasingly apathetic public.

    Let’s use an analogy so that the readers can educate their friends about this situation: Government wants to increase the number of college graduates. It does this by increasing the number of high schools and high school enrollment. Then they take to the airwaves and get the public riled up about this movement. While the public is in its lustful state over all this, government actually cuts college funding…and only a small minority of the public notices because it is too busy preaching “a college degree for all!”

  • 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. 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.

    • Suzi Q 38

      In general, the U.S. is lenient with most requirements compared to other countries.

    • namjemo

      Have you heard of Great Britain? Only thing needed is 1 exam PLAB. Secondly, sorry to burst your bubble, drs. in any country earn the most. Most IMGs here are due to unavoidable reasons. At the end, it’s life..can take you anywhere. But for you to assume that they are here for $$, I for sure wouldn’t want such patient!! I am hard working dr. , want the best for my family, and I give back 100% to my job. So why point fingers?
      Instead of making them take all the 3 boards, it can be dealt with 1 exam. That’s what is in all the countries.
      As far as playing by rules, these IMGs, have already played by the rules and passed all the boards in the home country. Let’s not pretend that only drs that are qualified are made in US. Wake up!

      • amohtap

        Passing the boards in their home country isn’t the same as passing the boards in America. We have different approved treatments, different procedures, different medications. The way we practice medicine is largely different. IMGs aren’t cogs in a machine that you can simply plop into place and expect them to work as advertised.

        And let’s be clear, much of the developing world produces questionable doctors to begin with. Having them pass the requisite board exams is the barest minimum we can place on incoming foreign doctors.

        Finally, your own example proves how stringent the US is. Passing the PLAB is simply the first step in obtaining a medical license in the UK. It’s not as simple as passing the PLAB and then getting a full, unrestricted medical license to practice medicine with, as you made it out to be. You still need to prove (or complete) that you have the necessary skillset to practice medicine in the UK and that entails much more than simply passing the PLAB.

    • namjemo

      to add, it’s like if someone comes to US in 10th grade, you would make them take exams for all the grades 1-10th !!

  • DiNovia

    The largest issue with IMG applicants to family medicine residency programs is not what country they did their training in but when they did it.

    Because of very real changes in health care delivery and technology, most university-bound residency programs require every applicant have graduated from medical school within the last five years. Many of the non-practicing potential IMGs “languishing” without a residency program are not only outside that date range but many are a decade or more outside that range.

    I don’t know if there’s a way to remedy that issue, but it is an issue I face every single application season. Their stories are compelling and their desire to work palpable, but university protocol is immutable on this criteria. And not just for family medicine, but for every specialty.

  • buzzkillerjsmith

    Canada of course has a huge primary care doc shortage as well. The article states that they actually vet the med schools where IMGs went and give them a break if the schools are up to their standards. Interesting.

    Primary care is a pretty crappy job and getting worse, so IMGs will likely have a bigger role as Americans make other choices. Subpecialties of course. Finance, perhaps?

    I know a woman doc who married a Brit and went to England. She had to repeat her entire residency. We’re not the only ones who want some evidence of competence in IMGs.

    • ninguem

      Gotta admit though, buzz, IMHO it’s a shame that we can’t get reciprocity with the Anglophone British Commonwealth.

      Maybe I’m off-base, I’d just think if I’ve got a Fellow of the Royal College of Surgeons, I’d expect comparable competency to the American College equivalent.

      Because of easy travel and relocation in the EU, they are working on standardization of their higher educational and professional educational systems, I think it’s called the “Bologna Accord”.

      As in the city, though the name does seem an easy invitation for jokes.

      • guest

        There was a place we used to drive past in Georgia, that served fried bologna sandwiches. They had a big sign out front advertizing that, and it said “HEY, YOU’RE FULL OF BOLOGNA!” Bring on the Bologna Accord, I say! :-D

  • Stephen Sutherland

    If US medical students prefer not to pursue Primary care, it seems reasonable fix those reasons. Otherwise someone from another country or a mid-level practitioner will also avoid this area.

    Likewise I also saw a crazy idea of having them just take a written exam and start providing services right away without residency.

    There are so many crazy ideas being tossed around that we are basically at a stand off

    • Suzi Q 38

      You are talking “reality.”

      If there is going to be as big of a shortage as the medical public thinks there is going to be, the government will find a way to remedy the situation.

      Maybe not just the exam alone, but a special residency program that takes less time and costs less money.

      This is provided that the physician has already completed h/her residency program in their native country.
      I am sure that some of the surgeons and physicians have treated patients with extensive injuries and medical conditions.

      Practicing medicine in Syria or Egypt might be a challenge right now.

      They would have done so with few resources and not enough hospitals.

      They could get through a reasonable residency program.

      If there is a need, someone will come up with a solution.
      Not everyone will agree or like it, but it could get interesting.

      • Stephen Sutherland

        fast tracking ‘foreigners’ to do a job that is extremely challenging is not a solution. It would be better to fix the work conditions.

        However, I have seem some very influential people propose such schemes. I’m sure they were not planning on getting their medical services through such avenues — i’m sure they have a tiered system in mind.

        And then finally how does such schemes affect the position of physician primary care providers. Does it reduce their reimbursement even further? I think so.

        So these things are really all bad ideas.

        • Suzi Q 38

          I agree.
          The “sky is falling” predictions are understandable.

          It is best to defend your “turf” a bit. You have every right to do so.

          On the other hand, there are some doctors that claim that there will be this huge shortage of PCP’s.
          One doctor on this web site told me something like “Good luck finding a PCP…” With threats like that, who wouldn’t look at other options???

          The government will find a solution, either with more medical schools for PCP’s or loan forgiveness as an incentive. I think that PCP’s also need to be paid more.

          They may also approve the licenses of more NP’s and PA’s.
          In addition, the use of foreign nationals may be another viable solution.

          In some cases, depending on the foreign physician, their medical and surgical skills may be very, very good. I would not underestimate this group.

          • Stephen Sutherland

            If the reimbursement rate is totally unacceptable for physicians — then i guess NPs and PAs and anyone else they can get their hands on would be assigned to do triage work for specialists. The specialists as MDs would exert have more control over the system and demand that the NPs and PAs refer everything to them.

            an average american might then make regularly scheduled visits to the Endocrinologist, Cardiologist , GI doctor and the Deramtologist.

            The cost of health care would go through the roof. So it’s important not to let that happen.

            I am under the impression the only reason for the primary care shortage was the reimbursement rate policy and the only way to the shortage is to correct the reimbursement policy.

            But another way to address this issue is by practicing full spectrum family medicine by providing all the procedures within the AAFP documented scope of practice for family physicians and more. Providing those procedures is diagnostic, curative, it’s great for patient convenience and better represents the scope of practice that family physicians should occupy. That’s another alternative for making primary care physician viable with a reimbursement system that heavily favors proceduralist.

            Procedures within the scope of practice of a family physician in case you don’t know include colonoscopy, EGD, colposcopy, EKG and a whole long list. In the 1990s maybe 1996 an organization decided on standardize set of procedures the family physician should be learn in residency. Until that point FM residents training in procedures were varied. So Family medicine is definitely a rich and viable field — and medical students should really not be intimidated by the current proposals as long as they practice full spectrum family
            So those are some solutions that i think will make family medicine primary care viable forever.

          • Suzi Q 38

            Thank you for your explanation and ideas.
            You make so much sense.

      • Guest

        “If there is going to be as big of a shortage as the medical public thinks there is going to be, the government will find a way to remedy the situation.”

        — — — — –

        Dear naive child, if you were to put the government in charge of the Sahara Desert, in 5 years there’d be a shortage of sand.

        Government is not the answer.

        • Suzi Q 38

          You are probably right about that one.
          I still think you are a troll.
          Take a huge “step”, be brave, and pick a fake name.

          You are the one that is naive if you think there the PA’s and NP’s will not be routinely utilized in the future.

          If there is a true shortage of PCP’s, the foreign doctors will be utilized as well.

  • ninguem

    Actually I reject the premise.

    “……The United States already faces a shortage of physicians in many parts of the country, especially in specialties where foreign-trained physicians are most likely to practice, like primary care…..”

    One, there is no physician shortage. That fact that there is a shortage of people willing to act against their self-interest, does not mean there is a shortage of physicians.

    Two, foreign nationals, trained outside the USA, who migrate to the USA to practice, have been shown by decades of experience, to follow the same demographic patterns as USA physicians, which makes all the sense in the world. If a place is not desirable for a doc from Cleveland, it is equally undesirable for a doctor from New Delhi.

    And such foreign doctors, in fact, are more likely to enter specialty practices than USA doctors.

    • Suzi Q 38

      “…One, there is no physician shortage. That fact that there is a shortage of people willing to act against their self-interest, does not mean there is a shortage of physicians….”

      Problem solved. If there is no physician shortage, why all the controversy and debate?

      “……Two, foreign nationals, trained outside the USA, who migrate to the USA to practice, have been shown by decades of experience, to follow the same demographic patterns as USA physicians, which makes all the sense in the world. If a place is not desirable for a doc from Cleveland, it is equally undesirable for a doctor from New Delhi….”

      This is an excellent point in theory, but a generalization.
      I would like to know where you get such a result. It makes sense though. Do you have any links to any articles?

      Same with my answer: No study, just human observation.

      Foreign nationals may start their American lives in larger cities where they have heard that they can find work. They also tend to start out in cities where other family members or friends have settled.
      Part of the reason is that some parts of our country are very welcoming towards immigrants, and others are not so positive about them. They will go where they feel comfortable at first.

      This is understandable. In time, after the initial move, they may feel comfortable enough to “branch out” to other states and cities.

      The first move is usually fueled by a job or job training as the catalyst.
      When faced with working each day at the car wash or convenience store VS. the possibility of being a physician again in a city that needs physicians, they may go for it.

  • buzzkillerjsmith

    Slightly off topic, but still having to do with the primary care shortage. I had interesting conversation with an NP we just hired. She used to work in a community health center in the Seattle. They have lost 18 of their 40 docs, NPs and PAs in the past few years. She describes working conditions as very bad: get in at 8 am, see a bunch of pts with much double-booking of appts, then working the EHR until 9 pm. All under the strict supervision of a businessman. Apparently the CHC gets paid on a per visit rate. I’m not sure how other ones get paid.

    She also states friends in other community health centers in her area have similar jobs, quite nasty indeed. They keep their CVs updated. And ramping up community health centers and hiring NPs and PAs to replace or augment us in those places is supposed to go a long way towards taking care of the shortage. Well, maybe things are better in Portland….

    CHC workers please chime in!

    • https://www.facebook.com/arobert6 Alice Robertson

      You just described my friend’s ACO practice but let me say his bonuses are wildly wonderful. They keep super busy keeping costs down because they get bonuses, and sometimes kill an elderly patient….but they are practicing the “live and learn” model:)

  • Tran

    Guidestar and Charity Navigator are very handy resources.

  • buzzkillerjsmith

    I can find it on Guidstar but not CN. It looks as if it cost 125 bucks to get the info. Can’t find it on Google.

  • Guest

    Hot Lips here got her PA certificate from Cuyahoga Community College. That’s pretty much the same as a BM BCh (Hon.) from Oxford, innit?

  • Adolfo E. Teran

    Interesting article, I’m a IMG practicing medicine, I become ECFMG certified before entering residency.

    • Suzi Q 38

      Bravo.

  • namjemo

    Let’s not make it out of proportion. I am able to speak Russian, even though I am not from Russia. When the Russian pts. know that , they prefer to come to me, because of the lang. barirer. It has nothing to do with my skin color. I have also seen that in many other minorities. So that’s what the OP was saying here.

    • Suzi Q 38

      I agree. Being able to speak several languages is a plus when your patients request it.

  • kjindal

    A question for those on both sides of this issue:
    -who would you trust more to be your elderly mother’s primary care medical provider – an FMG from, e.g., Ross univ in the Caribbean, who is board-certified in internal medicine, or an NP who trained at Yale, and also is certified by the equivalent of his/her Boards in geriatrics?

  • guest

    I have practiced as a P.A. for 17 years in a rural/underserved clinic and hospital. I have had the opportunity to work with many IMG through the J-1 visas. They are some of the best I have ever worked with. I agree, making this transition easier would help the physician shortage. It’s gotten so “tight” we have been searching for a full time physician for 2 years with no luck.

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