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.