Doctors With Borders: How the U.S. Shuts Out Foreign Physicians
MDs trained overseas must go through an often prohibitively difficult, time-consuming process.
HYPERLINK “Philip Sopher, The Atlantic” PHILIP SOPHERNOV 18 2014, 10:00 AM ET
In A Moveable Feast, Ernest Hemmingway details his time in Paris in the 1920s, dedicating a section to his friend F. Scott Fitzgerald. In this part, Gatsby’s creator is depicted as, among other things, a hypochondriac. In one of Fitzgerald’s dramatic fits, he insists on going to the HYPERLINK “Accueil | American Hospital of Paris” American Hospital in Paris because, “I don’t want a dirty French provincial doctor.”
Nearly 100 years later, the American Hospital in Paris continues to thrive. On its staff are HYPERLINK “FAQs | American Hospital of Paris” eight American doctors as well as HYPERLINK “http://www.american-hospital.org/en/american-hospital-of-paris/facts-figures.html” 378 European ones. It is the only hospital in Europe where a doctor can practice with a U.S. medical license. American doctors hoping to work in Europe HYPERLINK “http://www.nhscareers.nhs.uk/explore-by-who-you-are/international-healthcare-professionals/information-for-overseas-doctors/” would normally have to re-do their residencies before practicing independently.
The United States also has strict policies regarding medical licensing—a doctor is only allowed to practice in the U.S. once he has obtained a license in the state in which he intends to work. HYPERLINK “http://www.ama-assn.org/ama/pub/about-ama/our-people/member-groups-sections/international-medical-graduates/practicing-medicine/ecfmg-certification-information.page?” The person must acquire a visa, pass the first two steps of the United States Medical-Licensing Exam (USMLE), then become certified by the Education Commission for Foreign Medical Graduates (ECFMG), get into an accredited U.S. or Canadian residency program, and finally, go back and pass step three of the USMLE. Each of these steps could take multiple years, repelling doctors who are already able to practice in the country in which they were trained.
But is it really a good idea to deter them? By 2020, America’s doctor shortage is projected to reach HYPERLINK “Dr. Howser's Army: The 3-Year M.D. - The Atlantic” 91,500 too few doctors, with nearly half of the burden falling on primary care. This means doctors will be overworked and citizens may have to wait longer and pay higher fees for an appointment.
Without all of these barriers, many foreign doctors would find the prospect of migrating to the United States appealing. Dr. Arun Gadre, an otologist originally trained in India and now practicing at the University of Louisville, explains, “Arguably [the U.S.] is the only country in the world where one can do cutting-edge research, practice cutting-edge medicine, and still make a decent living.”
“Repeating the residency is not an easy thing. It’s made me wish I were allowed to skip some steps.”
Dr. Faris Alomran, a British-educated vascular surgeon working in France, says, “My first choice after medical school was to practice in the U.S. In fact, for most [English-speaking] people, in terms of language options, they are somewhat limited to Australia, Canada, and the U.S.”
But he didn’t end up crossing the Atlantic. “In the U.S. I would have had to do five years of general surgery and a two-year fellowship in vascular surgery to be a vascular surgeon. Seven years total. I got an offer in Paris to do a five-year vascular surgery program. They also reduced my training by one year since I had done two years in the U.K.”
Juliana, a physician originally trained in Brazil and currently in an American residency program, agrees that migrating to the U.S. could have been easier, especially if redundant training were removed. “Repeating the residency is not an easy thing, and many times it’s very frustrating. I do not think the internship [that I’m in] will add much to my future career. Having trained in America for the last four months has helped me understand cultural differences [between the U.S. and Brazil], but it has also made me wish I were allowed to skip some steps.”
Though re-doing her residency has been frustrating, it was an achievement to get accepted into a program in the first place. Locking up a coveted residency post is a HYPERLINK “http://healthaffairs.org/blog/2014/04/24/the-2014-gme-residency-match-results-is-there-really-a-gme-squeeze/” significant hurdle for foreign-trained doctors. All U.S. states HYPERLINK “http://www.fsmb.org/public/public-resources/state_specific” require at least one year of residency in an accredited American or Canadian program to qualify for a medical license. Though the number of students in medical schools has increased, the number of accredited residency positions HYPERLINK “Residency shortage leaves hundreds of med students in debt-laden limbo” has remained relatively stagnant since 1997.
American Medical Association President Robert Wah recognizes this residency bottleneck. “U.S. residency program positions have not increased at an adequate rate to accommodate the expanding number of U.S. medical graduates and the current IMG [International Medical Group] applicant pool,” he said in an email.
Even if the AMA were to magically produce a few thousand more residency slots, it would barely make a dent in 91,500 projected doctor shortage.
Whittling down the shortage will likely take a combination of measures. HYPERLINK “Dr. Howser's Army: The 3-Year M.D. - The Atlantic” Three-year medical degree programs, reduced from the typical four years, already exist at NYU, Texas Tech, and Mercer. Ohio wants to HYPERLINK “Conquering the doctor shortage” expand the roles of physician assistants and nurse practitioners, allowing them to take on more of doctors’ responsibilities. Earlier this year, HYPERLINK “http://online.wsj.com/articles/missouri-to-allow-med-school-grads-to-work-as-assistant-physicians-1405547613” Missouri passed legislation allowing medical school graduates to work as assistant physicians and treat patients in underserved areas, a measure that is controversial because at least one year of residency is usually required to practice independently.
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In addition to these strategies, reducing entry barriers for well-trained foreign doctors would be a way to immediately increase the U.S. doctor supply.
Those opposed to reducing entry barriers claim that the U.S. produces the best doctors in the world, and that HYPERLINK “http://www.nytimes.com/2013/08/12/business/economy/long-slog-for-foreign-doctors-to-practice-in-us.html?pagewanted=all&_r=0” bringing in more foreign physicians would reduce the quality of the country’s medical care. Gadre agrees that it’s important for the U.S. to maintain its high standards for medical practitioners. “In large countries like India levels of education and competence can vary vastly between the big cities and smaller towns due to a lack of standardization, and sometimes even corruption, in the educational system… So the AMA is correct in ascertaining that certain minimum standards must be maintained ”
However, there are plenty of highly skilled, foreign-trained doctors. Basketball player Kobe Bryant HYPERLINK “» Why Did Kobe Go to Germany?” opted to go to Germany to treat his knee. HYPERLINK “Complications: A Surgeon's Notes on an Imperfect Science - Atul Gawande - Google Books” \l “v=onepage&q=atul%20gawande%20shouldice%20hernia&f=false” According to Atul Gawande, the best hernia surgeons in the world are at HYPERLINK “http://shouldice.com/” Shouldice Hernia Center in Ontario, Canada. QS, a company that does worldwide university comparisons, HYPERLINK “QS World University Rankings for Medicine 2014 | Top Universities” \l “sorting=rank+region=140+country=+faculty=+stars=false+search=” ranks Oxford’s and Cambridge’s medical schools second and third in the world, behind Harvard’s and ahead of Stanford’s. Beyond diluting the quality of medical care, another fear is that more doctors coming to the U.S. would mean fewer talented doctors abroad. The Economist, however, HYPERLINK “Is there a doctor in the country?” disagrees with this reasoning, arguing that a chance to come to the U.S. would motivate more foreigners to study medicine, and most of them would stay in their home countries. A third fear is that loosening regulations would negatively affect U.S. medical schools. If coming back to the U.S. were easier, Americans might be more likely to study in places like England and Israel because becoming a doctor would be both cheaper and faster overseas. Further, an influx of doctors could impact a more sensitive matter—with an increased doctor supply, salaries among America’s white-coats would almost certainly go down. “Nobody wants to share their pie,” Alomran says. “This is the same everywhere and is not unique to medicine, in my opinion.” Nonetheless, Wah claims that the AMA supports rule changes that make it easier for foreign doctors to transition to practicing in America as long as the quality of medical care does not suffer. “We [the AMA] support the development and distribution of model legislation to encourage states to amend their Medical Practice Acts to provide that graduates of foreign medical schools meet the same requirements for licensure by endorsement as graduates of accredited U.S. and Canadian schools,” he says.
May 9, 2006
Infants Dying for Lack of Basics, Report Says
By HYPERLINK “Celia W. Dugger - The New York Times” \o “More Articles by Celia W. Dugger” CELIA W. DUGGER
More than four million newborns worldwide die each year in their first month of life, comparable to the number of babies born in the United States annually, Save the Children reported Monday.
Many of those infants could be saved with simple, inexpensive items, like sterile blades to cut the umbilical cord, antibiotics for pneumonia and knit caps to keep them warm, the group said in “State of the World’s Mothers 2006,” a new report. Ninety-nine percent of newborn deaths are in developing countries, where such items are often not widely available.
The deadliest time for children is in the hours after birth, and the deadliest places are the poorest corners of world. South Asia and Africa have the highest rates of newborn deaths, Save the Children said. “The first day of life is the most dangerous day a human being has,” said Charles MacCormack, president of Save the Children.
While many countries have significantly lowered mortality rates for children younger than 5 in recent decades, the group said, little progress has been made globally in preventing the deaths of newborns and their mothers.
But researchers for Save the Children, a nonprofit group that works in more than 40 countries, found that some developing countries that have made newborn and maternal health a priority — among them Indonesia, Eritrea, Nicaragua and the Philippines — have succeeded in cutting newborn death rates.
Countries that are performing worse than expected compared with nations at similar levels of wealth include Angola, Ivory Coast, Mali, Pakistan and Sierra Leone.
In the United States, 4.7 newborns die of every 1,000 born, compared with 12 per thousand in Vietnam, the developing country with the lowest rate, and 65 per 1,000 in Liberia, which has the highest rate.
“Three out of four newborn deaths could be avoided with simple, low-cost tools that already exist,” Melinda Gates wrote in an introduction to the report. The Bill and Melinda Gates Foundation has given $110 million to support Save the Children’s work to reduce newborn and maternal mortality.
President Bush’s budget for the 2007 fiscal year proposes spending $323 million on maternal and child health programs in the United States Agency for International Development, less than the $356 million Congress appropriated last year. Save the Children is supporting a House bill that would instead increase financing. Mr. MacCormack said the amount of such aid had been flat through the past three administrations.
While the Bush administration’s proposed budget would reduce spending for such programs within the aid agency, administration officials note that it would sharply increase spending on AIDS and malaria, afflictions that kill hundreds of thousands of babies and children, particularly in Africa.
Successful countries have made it a priority to provide prenatal care, birth attendants and immunization programs to prevent tetanus in newborns and mothers, the report said. Parents also must be educated about the importance of breast-feeding from the very start, the group recommended, and not introduce other liquids that contain dirty water and can cause diarrhea, often deadly to a weakened newborn.
Another way to reduce deaths is to give women access to modern contraceptives, the group said. Birth control, it said, allows enough time between births to preserve the mother’s health and reduce the likelihood that their babies are born with low birth weights. The New York Times.
ABC News
Longer Lives Mean Headaches for Health Care Industry
The Elderly-Care Industry Battles Personnel Shortages While Bracing for Influx of Aging Boomers
By ERIC NOE
Oct. 24, 2005 — - The elderly-care industry is facing a human resources problem. As the number of aging Americans grows, the ranks of elderly-care professionals – from registered nurses to paraprofessionals who make home visits – remains stagnant, and is even shrinking in many areas.
Low wages and hard working conditions make it difficult for nursing homes and home-care providers to recruit and retain qualified employees. With the baby boomer generation approaching 60 and life spans expected to grow, some fear the industry is not prepared to handle the influx of aging patients.
“We all know the boomer demographic is aging and that life spans are lengthening, and I think there is a crisis coming,” said Ann Marie Cook, chief executive officer of Lifespan, a nonprofit agency in Rochester, N.Y., that helps older adults and families find elderly care. “The crisis might not happen immediately, but it would be ill-advised to not address the problem now.”
Many hope that aggressive recruiting and incentive programs will attract a new generation of professionals into elderly care. And the introduction of home-care technology, including caring for patients through teleconferencing, could allow nurses to see more patients and relieve some of the industry’s staffing problems.
Americans are Living Longer
In 1900, the average American life span was about 47 years, according to Jeanette Takamura, dean of Columbia University’s School of Social Work and former assistant secretary for aging in the U.S. Department of Health and Human Resources. The average life span is 78 today; by 2030, there will be double the number of Americans over the age of 65, pushing today’s number to 72 million. With better medicine and technology, Americans are expected to continue living longer, healthier lives.
That’s a daunting concept for a traditionally cash-strapped industry. Long-term elderly care, particularly for nurses, has historically been a low-paying field. Providers often are unable to compete with the salaries offered by hospitals or other health care organizations.
Some companies are aggressively recruiting nurses and paraprofessionals, offering small bonus incentives, educational benefits or ladder programs that eventually move nurses into management positions. One home-care nursing company, Visiting Nurse Service, also in Rochester, instituted a program in which one year of paraprofessional service earns workers full tuition to a college program that trains them to become Licensed Practicing Nurses.
“We’re telling people who are interested that this can be a career rather than just a job,” said Victoria Hines, CEO of Visiting Nurse Services. “It’s become a recruiting tool.”
But financial constrictions along with the negative stigma of working with frail elderly patients have made it difficult to recruit and retain staff. Hines noted that even with increased enrollment this year, the new paraprofessionals in the program only replaced the ones who dropped out in early 2005. The annual turnover rate for paraprofessionals in the elderly-care industry is about 40 percent to 50 percent nationwide, Hines said, and the nursing turnover is about 15 percent.
“Paraprofessionals still only make about $8 an hour, and that’s for visiting five homes a day doing hard, physical labor. They could make the same amount of money working at a retail store,” she said.
Nursing Homes Changing Focus
In addition to personnel shortages, elderly-care businesses are adjusting some long-standing practices. The construct of the traditional nursing home has changed considerably in the past decade. The focus during the previous 40 years had been on creating modern, hospital-like settings for aging patients to live in and receive care.
But aging Americans are less and less willing to move into nursing homes, believing they feel too institutional. More often, today’s elderly want the freedom to live in their own homes or to live with family members, so the number of long-term nursing home inhabitants has declined. Columbia’s Takamura said only about 4 percent to 5 percent of the country’s elderly population now lives in nursing homes.
“There’s been a market shift. Consumers want choice,” said Bruce Yarwood, president and CEO of the American Healthcare Association, who worked in the nursing home industry for more than 30 years.
But living longer lives means many people are living with chronic conditions that require professional care. Family members are not always able to take time off work or to offer the kind of specialized treatment that health care workers are trained to provide. So house calls may once again become commonplace.
“Looking forward, the biggest growth area is going to be in home care,” Yarwood said.
This shift and the impending boomer retirements pose several challenges. Elderly-care facilities are searching for methods to balance their personnel shortages with the need to serve off-site patients. And some current nursing staffers need to be retrained to perform care services in patients’ homes.
Working With Technology
Some have found that installing technology like video conferencing, known as telemedicine, allows their staff to reach a greater number of patients.
“A nurse capable of managing people outside of a hospital or home can see maybe six or seven patients in the course of a day. But that number could jump to two dozen or more if they’re using video conferencing,” said Larry Minnix, CEO of the American Association of Homes and Services for the Aging. “That’s one way to address the personnel shortage without being impersonal with the patients.”
Hines agreed. But she pointed out that Medicare and Medicaid have been slow to embrace telemedicine. The government insurance programs often don’t reimburse patients for telemedicine treatment, making such treatment difficult for many patients to use.
But as patient loads increase and health care staffing is stretched thin in coming years, Hines said that telemedicine is the logical next step.
“You’re going to eventually reduce the need for nursing intervention by setting up telemedicine capabilities,” she said. “It’s all about efficiency – sending one person to one home is just not an effective use of time when that one person could be serving several people.” Using technology to streamline filing systems could help cut down expenses and avoid costly liability lawsuits. Minnix said 50 percent of all liability cases stem from faulty or insufficient filing. Moving to wireless, paperless systems, though costly at the outset, could prevent bigger financial losses in the future, he said.
“The next wave is really creating the technology that allows people to stay at home and allows the health care industry to treat them,” Minnix said. "“Our business has to be smart about how they understand the technical capabilities of their investments, but in the long run it could save them money and help them treat more people.”
Copyright © 2005 ABC News Internet Ventures
Lure of Great Wealth Affects Career Choices November 27, 2006 GILDED PAYCHECKS By HYPERLINK “Louis Uchitelle - The New York Times” \o “More Articles by Louis Uchitelle” LOUIS UCHITELLE A decade into the practice of medicine, still striving to become “a well regarded physician-scientist,” Robert H. Glassman concluded that he was not making enough money. So he answered an ad in the HYPERLINK “New England Journal of Medicine - The New York Times” \o “More articles about New England Journal of Medicine” New England Journal of Medicine from a business consulting firm hiring doctors. And today, after moving on to Wall Street as an adviser on medical investments, he is a multimillionaire.
Such routes to great wealth were just opening up to physicians when Dr. Glassman was in school, graduating from Harvard College in 1983 and Harvard Medical School four years later. Hoping to achieve breakthroughs in curing cancer, his specialty, he plunged into research, even dreaming of a HYPERLINK “Nobel Prizes - The New York Times” \o “More articles about Nobel Prizes.” Nobel Prize, until Wall Street reordered his life.
Just how far he had come from a doctor’s traditional upper-middle-class expectations struck home at the 20th reunion of his college class. By then he was working for HYPERLINK “http://www.nytimes.com/redirect/marketwatch/redirect.ctx?MW=http://custom.marketwatch.com/custom/nyt-com/html-companyprofile.asp&symb=MER” \o “Merrill Lynch” Merrill Lynch and soon would become a managing director of health care investment banking.
“There were doctors at the reunion — very, very smart people,” Dr. Glassman recalled in a recent interview. “They went to the top programs, they remained true to their ethics and really had very pure goals. And then they went to the 20th-year reunion and saw that somebody else who was 10 times less smart was making much more money.”
The opportunity to become abundantly rich is a recent phenomenon not only in medicine, but in a growing number of other professions and occupations. In each case, the great majority still earn fairly uniform six-figure incomes, usually less than $400,000 a year, government data show. But starting in the 1990s, a significant number began to earn much more, creating a two-tier income stratum within such occupations.
The divide has emerged as people like Dr. Glassman, who is 45, latched onto opportunities within their fields that offered significantly higher incomes. Some lawyers and bankers, for example, collect much larger fees than others in their fields for their work on business deals and cases.
Others have moved to different, higher-paying fields — from academia to Wall Street, for example — and a growing number of entrepreneurs have seen windfalls tied largely to expanding financial markets, which draw on capital from around the world. The latter phenomenon has allowed, say, the owner of a small mail-order business to sell his enterprise for tens of millions instead of the hundreds of thousands that such a sale might have brought 15 years ago.
Three decades ago, compensation among occupations differed far less than it does today. That growing difference is diverting people from some critical fields, experts say. The American Bar Foundation, a research group, has found in its surveys, for instance, that fewer law school graduates are going into public-interest law or government jobs and filling all the openings is becoming harder.
Something similar is happening in academia, where newly minted Ph.D.’s migrate from teaching or research to more lucrative fields. Similarly, many business school graduates shun careers as experts in, say, manufacturing or consumer products for much higher pay on Wall Street.
And in medicine, where some specialties now pay far more than others, young doctors often bypass the lower-paying fields. The Medical Group Management Association, for example, says the nation lacks enough doctors in family practice, where the median income last year was $161,000.
“The bigger the prize, the greater the effort that people are making to get it,” said Edward N. Wolff, a HYPERLINK “Times Topics - The New York Times” \o “More articles about New York University.” New York University economist who studies income and wealth. “That effort is draining people away from more useful work.”