BY: MARK CRAWFORD
It is well-known that the United States is facing a serious shortage of physicians — a situation that will only get worse in the coming years. About one-third of all physicians over age 55 are planning on retiring soon, which also will add to the shortage. Predictions vary, but according to the American Association of Medical Colleges, by 2025 the U.S. will be short about 160,000 physicians.
The U.S. Department of Health and Human Services estimates there were 5,848 "primary medical health professional shortage areas" in the country in 2012 and that "it would take an additional 15,928 physicians to adequately meet the primary care medical needs of people in those areas," according to cardiologist David J. Skorton, MD, president of Cornell University, in a Feb. 20, 2013 blog entry for the Huffington Post.
The changing work habits of younger physicians are another factor. On average, new physicians want to work five fewer hours per week — equivalent to losing about 40,000 more doctors. Also, as the number of physicians continues to decrease, the number of patients will continue to increase, with millions of previously uninsured individuals seeking care under the Affordable Care Act and with Baby Boomers retiring in large numbers.
"Currently there are just over 800,000 physicians in the U.S.," said Jim Stone, president of Medicus Firm, a physician recruiting company based in Dallas. "Of these, about 30 percent are foreign-born or foreign-trained. We simply don't have enough physicians — foreign doctors are absolutely essential for delivering care in this country."
Because of this shortage, health care systems across the country rely on foreign medical graduates, commonly called FMGs, to help meet physician hiring needs. The top three areas of practice for FMGs are all in primary care — internal medicine, family medicine and pediatrics — three practice specialties that are in high demand.
"Moreover," said Francine Kyaw, division director for physician recruitment for Catholic Health Initiatives' (CHI) Fargo, N.D. operating division in the upper Midwest, "their immigration status and work visas often require them to fill much-needed physician positions in health professional shortage areas or medically underserved areas. Thus recruiting FMGs also supports CHI's diversity and inclusion efforts."
Even though foreign-born doctors are in such high demand, they must go through arduous U.S. training requirements and a complex and often confusing immigration/visa process. All FMGs must also complete an accredited residency training program in the U.S. or Canada, a process that takes at least three years.
The process for getting accepted as a resident in a teaching hospital can be complicated. The roughly 18,000 American medical school students who graduate each year are the first to be allocated slots in the pool of 25,000 residency positions across the country. After every American medical school graduate secures a residency position, the remaining slots, about 6,000 to 8,000, are opened up to FMGs.
"The competition is so fierce that only the top graduates of foreign medical schools have a chance of getting into a U.S. training program," said Greg Siskind, a physician immigration attorney with Siskind Susser in Memphis, Tenn. "It's really not a surprise, then, that when you look at the faculty of the top academic medical centers in the U.S., the doctors are disproportionately foreign-born."
Foreign doctors typically apply for either the J–1 or H-1B visa, neither of which the U.S. government classifies as an immigration visa.
The J–1 visa is an exchange visitor visa for approved individuals to participate in certain U.S. work and study programs. The Educational Commission for Foreign Medical Graduates, headquartered in Philadelphia, sponsors and supervises foreign-educated physicians who wish to enter accredited clinical training programs in the U.S. under a J–1 visa. After their U.S. training program ends, the visa holder is required to return to his or her home country (or country of last residency) for two years.
"The two-year home residence requirement prevents a physician from obtaining a work visa or permanent resident status upon completion of training until the requirement is met or is waived," stated Jeffrey S. Bell, an attorney with Polsinelli PC in Kansas City, Mo. "It is not uncommon for FMGs who want to begin their medical career in the U.S. to seek a waiver of the two-year home residence requirement."
The H–1B is for highly educated, skilled workers in certain specialties whose American employers petition for the visa on the individual's behalf. A teaching hospital wishing to hire a particular foreign-born medical specialist would be a good example.
Before they are awarded the H–1B visa, however, FMGs are required to pass all three parts of the United States Medical Licensing Examination. "They must also have the necessary license for the state in which the training will take place," added Siskind.
The H–1B visa has an overall limit of six years in the U.S. Physicians coming out of residencies might have three years of H–1B time remaining, while physicians finishing fellowships might have only one or two years left. "Therefore facilities need to be mindful of how much time is left on a candidate's H–1B clock, as it may make little sense to expend resources on a physician who can work only for a short time," added Bell.
From a health system's perspective, the J–1 application process is far less expensive and burdensome because the Educational Commission on Foreign Medical Graduates sponsors the entire J–1 program. For H–1B visas, an institution must be the petitioner and comply with various legal requirements and pay government filing fees (as well as any attorney fees, if needed).
SERVING RURAL AREAS
Many health systems struggle to find physicians willing to work in rural areas, removed from the cultural benefits and other advantages that larger cities provide. According to the Medicus Firm's 2013 Physician Practice Preference and Relocation Survey, only 13 percent of the 2,568 respondents practiced in a small town or rural area (population under 25,000). When asked the size of the community in which they would prefer to live, only 1.8 percent of physicians in training chose a rural setting.
Hospitals are always hopeful that FMGs will want to practice (and stay) in these areas; however, just like American doctors, FMGs vastly prefer the diversity that bigger communities provide. Many FMGs carry out their residencies in rural areas but don't remain, choosing to practice in a city or, under the terms of their visa, returning to their home country.
Kyaw can attest to the challenges of recruiting in rural areas. Her work in CHI's Pacific Northwest and Fargo, N.D., divisions includes advertising eligible positions, accepting FMG candidates and attending recruitment events and job fairs in areas with high numbers of FMGs in residency programs.
When a physician is getting established, his or her main concern — American or foreign-born — is being accepted into the community, she said. Employers with a solid, multifaceted recruitment and retention program can help.
"There are several activities employers can implement to help with this integration," said Kyaw. "A mentor or buddy can be assigned to the physician to aid in introduction and acclimation to a new practice environment. Other considerations are a robust orientation and onboarding program, welcome social for the physician, annual business/social medical staff meetings and regular recruitment/retention check-ins during the first year."
A physician's language skills are critical — effective communication between a physician and the patient and patient's family helps establish trust and ensure the highest-quality outcomes. All FMG physicians are required to pass English language competencies. "However," noted Kyaw, "a comprehensive screening and evaluation during the interview process is what identifies the challenges and opportunities for improvement. Communication issues can be overcome through speech pathology and accent-reduction training as part of onboarding, as well as cultural diversity training — both of which are not commonly encountered or taught in residency."
CHI has developed several residency and fellowship programs and continues to explore avenues and dedicate resources to expanding them.
"We are committed to the immigration and legal needs of our FMG physicians and their families," said Kyaw. "CHI sponsors and pays for all fees related to the J–1/H–1B process. We also support physicians in good standing who seek permanent residency status. At Franciscan Health System in Tacoma, Wash., we routinely accept and hire between two and five J–1/H–1B physicians every year, and sponsor several others for permanent residency status."
Health systems may find it beneficial to work with physician immigration lawyers, who know how to streamline the process and sometimes represent top FMG candidates.
"Employers considering international medical graduates should talk to an immigration lawyer at the outset of the recruiting process to figure out what types of graduates can pursue the job, what sorts of provisions must be in the contract, what type of salary needs to be paid, restrictions on where the doctor would need to be working, etc.," said Siskind. "For some of my employer clients, I follow up their interview of the candidate with my own interview to make sure the employer is going to be able to sponsor the doctor under immigration law."
Congress is working on a major overhaul of physician immigration, which is included in Bill 744 (passed by the Senate in June 2013). The physician immigration provisions provide more flexibility regarding visa and residency requirements for international physicians, the number of available slots for residencies and waiver conditions. There is also a call to lift the per-country caps on green cards, which have caused major backlogs for Indian and Chinese physicians entering the U.S. to practice.
"Removing the barriers that prevent global talent from reaching our shores through comprehensive immigration reform would be a positive start," Skorton said in the Huffington Post. "As President Obama stated in his inaugural address, 'our journey is not complete until we find a better way to welcome the striving, hopeful immigrants who still see America as a land of opportunity; until bright young students and engineers are enlisted in our workforce, rather than expelled from our country.' Through enlightened immigration policies, we can address our physician shortage and be a beacon for the rest of the world."
MARK CRAWFORD is a freelance writer in Madison, Wis.
MEDICAL EDUCATION PARTNERSHIP INITIATIVE
One concern about loosening the restrictions on foreign doctors practicing in the U.S. is that it could take qualified physicians away from impoverished nations that may have subsidized their doctors' medical training with public funds, assuming their doctors will stay.
"The shortage of health professionals in the U.S. pales in comparison to the worldwide need, which the World Health Organization puts at about 4.3 million," said David J. Skorton, MD, president of Cornell University, in a Feb. 20, 2013, blog entry on the Huffington Post. "Especially in sub-Saharan Africa, the loss of trained physicians and other health workers to the West is making it even harder to secure the health of their citizens."
To counteract these effects, the Medical Education Partnership Initiative (http://mepinetwork.org/) was established to support academic centers in African countries and nurture the development of health care professionals. So far, the group has developed a network of 30 regional partners, country health and education ministries and more than 20 U.S. and foreign collaborators.
Academic institutions also are playing important roles. For example, Cornell University operates a branch of its Weill Cornell Medical College in Doha, Qatar.
"Students from Qatar, as well as from several other nations, earn a Cornell medical degree through the program," said Skorton. "In Tanzania, faculty members are on site to help train doctors. Although these programs are relatively small, they offer models for building capacity for health care in the Middle East, Africa and elsewhere."
WELCOME BACK INITIATIVE
For some foreign-trained, immigrant physicians, trying to get licensed to practice in the U.S. is simply too difficult, or too costly, and they withdraw from the process. To get by, they take other jobs in the health care field or accept entry-level service jobs — sometimes continuing to pursue their license to practice, and sometimes not.
San Francisco State University and City College of San Francisco launched the Welcome Back Initiative (www.welcomebackinitiative.org) more than a decade ago to provide counseling and support for foreign-trained health professionals. The goal of these free services is to help immigrant health care professionals obtain the credentials they need to practice in the U.S. as doctors, nurses or in other health care positions.
To date, the Welcome Back Initiative has worked with about 4,600 physicians, nearly half of them from Latin America, a particularly important group for California. With a Hispanic population approaching 40 percent, according to the U.S. Census Bureau, only a fraction of the physicians practicing in California are Hispanic or speak fluent Spanish and understand Hispanic/Latino culture.
Patrick Dowling, MD, a physician at the UCLA Medical Center in Santa Monica, Calif., established the International Medical Graduate Program to help Latin American physicians secure residency positions in primary care. Participants are required to work in underserved areas of California for three years.
During an April 2013 interview with National Public Radio, Dowling said hundreds or even thousands of talented immigrant doctors from Latin America could be practicing medicine — for which they are already educated and trained — instead of working at low-paying jobs. He called them a resource that is too valuable to waste.
"I was just reviewing an applicant this morning from someone currently working in McDonald's," said Dowling. "And I thought, the irony — she is serving people Big Macs right now, and what she could be doing, as a physician, is explaining to people this isn't what they should be eating."
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