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

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

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

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

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

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

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

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

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