Challenges Foreign Physicians Face in Finding Employment in the U.S.
By Joyce Routson
Shortage of residencies the main roadblock
By Joyce Routson, HEALTHeCAREERS.com
Americans are just starting to awaken to the fact that a physician shortage in this country may push an already-packed medical system to beyond capacity when 30 million potential new patients are added to the insurance rolls under the healthcare reform law.
Various medical groups have warned that there could be a need for more than 100,000 new physicians by the end of the next decade. The need will be especially acute in primary care.
While the reform act does provide some funding for primary care doctors, physician assistants and nurse practitioners to address the newly insured, a growing population and the needs of aging baby boomers will never close the gap.
But what if there was a qualified workforce of 11,000 doctors ready to help, who can't practice medicine in the U.S.?
That is the estimated number of international medical school graduates (IMGs) who apply for residencies each year. Fewer than half of them are accepted, due to a shortage of training programs.
Physicians who graduated from medical schools outside the United States (with the exception of Canada) must complete a residency training program here before they can become licensed to practice medicine. The requirements for IMGs are complicated and include the U.S. Medical Licensing Examination (USMLE). In addition, the process for obtaining a visa to study in the U.S. is lengthy and complex.
According to the Educational Commission on Foreign Medical Graduates (ECFMG), 22,809 first-year residencies were offered in what is called "the match" this March. Of the 11,048 IMGs who applied, only 42 percent were matched. Ninety-three percent of U.S. medical school seniors matched to a first-year residency position this year, according to the National Resident Match Program, which compiles the data.
"There are many doctors available who can contribute to society who cannot practice because of the three-year residency requirement," says Dr. Vinod K. Shah, MD, FACC, president of the American Association of Physicians of Indian Origin.
"Residencies go first to U.S.-born physicians. If they're given a choice, they take a U.S. grad first before an IMG."
Neither organization had a recent breakdown of U.S. vs. non-U.S. students matched to various specialties. But the trend has been that more IMGs than U.S. graduates fill the critical family medicine and internal medicine slots. The American College of Physicians (ACP) reported that in 2007, only 56 percent of the internal medicine residency positions and only 42 percent of the family medicine residencies were filled by U.S. medical school seniors. The remainder was filled by IMGs.
"IMGs serve an indispensable role in providing primary care in many communities," the ACP wrote in a position paper in 2008. "The College has long recognized the value of IMGs and their contributions to healthcare delivery in this country. More IMGs choose internal medicine than any other specialty"
The reasons fewer IMGs are not matched to residency positions are several: There aren't enough residencies, due to budget constraints; it is more difficult for them to enter the prestigious programs at university affiliated teaching hospitals such as UCSF, Harvard or Stanford; and some residency programs are hesitant to accept individuals from schools with which they've had no experience.
The ACP has outlined a number of solutions to the problem, including increasing the number of residency positions. In the 2008 paper, it said, "Without an increase in residency positions, IMGs may be forced out of the U.S. healthcare system as more U.S. medical graduates will probably fill residency positions once filled by IMGs, leading to a less culturally diverse physician population."
Funding residencies is a big problem and the health reform bill didn't fully address the issue. The ACP wants to see more funding from Medicare, as well as from private insurers. "It can't just be the burden of the federal government as for-profit insurers get the benefit as well," says Dr. Steven Weinberger, MD, FACP, deputy executive vice president.
Some have called for an overall increase in medical school classes and new medical schools, but the ACP says that such an effort would do little to alleviate the shortage of primary care physicians. Weinberger says: "The problem is that if you increase the number of medical school grads and you don't increase the number of residencies, you force out a number of IMGs. That doesn't increase the number of physicians who go into practice."
Shah, a cardiologist who practices in Maryland, has a different take on how IMGs can get more of an edge in obtaining a residency. "You have to be very, very good," he says. "You have to compete with any doctor anywhere. You have to have a USMLE score as high as possible and be fluent in English."
He also advises, as does Weinberger, that foreign physicians try to find an observership or a job in healthcare that puts them into proximity to residency program institutions. "Whether it's research or a clerkship, try to expose yourself to the healthcare field," Shah says.
The ACP has also called for streamlining the process for obtaining visas for non-U.S. citizen IMGs who want to train here. Currently an IMG may apply for a J-1 visa after passing Step 1 and Step 2 of the USMLE, and obtaining a graduate medical training position. But the J-1 visa requires holders to return to their home country for two years following completion of training.
There are exceptions. If a physician commits to work for five years in an underserved area, typically in an inner city or rural community, he or she may apply to the Conrad 30 program. Each state sponsors 30 slots; in some states, they are snapped up the next day, in others they languish. In addition, some states do not sponsor specialists for the Conrad 30.
"It's really weird that a state like California has the same number of slots as Wyoming," says Los Angeles immigration attorney Carl Shusterman, about the population inequity. "In Wyoming there are always unused numbers because people don't want to go to Wyoming. All this competition between the states doesn't seem to me to be in the national interest."
Shusterman advises his clients to obtain an H-1B visa (for temporary professional workers), but fewer residency programs offer that kind of sponsorship. "Make sure the program you are trying to match with offers an H-1B so you won't necessarily be forced to go back to your country or work in an underserved area," he says.
Shusterman, like the ACP, is concerned about the looming physician shortage and says the public isn't being served. "Everyone does what's in their particular interest – if you keep the foreign docs out, the U.S. doctors do better. But the patients don't do better."
He says we should admire the worth ethic of doctors who immigrate, since it's a long slog. "When I was 24 I was already practicing law, but when [these doctors] are 30 they're still in a fellowship program. There are easier ways to be a professional than to go through all this. And fewer Americans are doing it."
Weinberger says if he had to practice in India, "I'd be in deep trouble. But these IMGs have the challenges of the language issue, learning a very different medical system and going through all the challenges of every life in moving to a different country. It's quite frankly remarkable what many of them are able to do."
Currently about 25 percent of all doctors practicing here are IMGs.