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A coming shortage of foreign-trained doctors?

Residencies have enough IMGs, but some see trouble ahead

From the September ACP-ASIM Observer, copyright © 2001 by the American College of Physicians-American Society of Internal Medicine.

By Phyllis Maguire

Waiver jobs becoming harder to find

Changes in the number of international medical graduates (IMGs) training in the United States are raising questions about the number-and the character-of the nation's physician workforce.

For the past five years, the number of IMGs entering the educational pipeline has sharply declined. While the number of IMGs actually working in U.S. training programs has so far remained steady, a drop in those numbers could have wide implications.

International graduates are the backbone of many U.S. teaching hospitals, particularly in the nation's inner cities and small communities. In addition, many foreign-born international graduates stay in America to practice after training and provide care in the nation's poorest rural areas.

Experts have identified several factors that may be hurting the number of IMGs who apply for U.S. training program slots. Educators, for example, say that some international graduates are discouraged by a relatively new certification requirement they must complete before entering training. And analysts note that changes in U.S. immigration policies are affecting the flow of foreign-born doctors to this country, producing more IMGs who are immigrants and fewer who come on temporary visas.

Beyond those points, however, there is relatively little agreement. Analysts disagree about whether a drop in IMG numbers will be good or bad for American medicine. Some say that a drop in IMGs might reduce a physician glut, while others predict that it would only complicate an ongoing shortage in underserved areas. One thing, however, is certain. Because foreign-educated physicians account for almost a quarter of the U.S. physician workforce, any change in the IMG community will alter the face of American medicine. Even now, as the supply of IMGs is just beginning to show signs of change, experts say they are already noticing subtle changes in the U.S. physician supply.

Shrinking pool

The number of IMGs entering U.S. training programs-6,000-has remained relatively stable. What concerns some educators and workforce analysts, though, is that the number of IMGs entering the graduate education pipeline has steeply declined.

In 1997, for example, more than 36,000 international graduate registrations for Step 1 of the United States Medical Licensing Examination (USMLE), which is typically the first element in their certification process. By 2000, that figure had fallen to less than 16,000.

According to the Educational Commission for Foreign Medical Graduates (ECFMG), which certifies IMGs for U.S. training programs, the number of J1 Exchange Visitor physicians sponsored in medical residency programs fell from more than 7,300 in 1995-96 to just over 5,600 in 1999-2000. (These figures do not include physicians sponsored for subspecialty fellowships or as research scholars.)

The number of non-U.S. citizen foreign graduate participants in the Match has also declined, from almost 8,000 in 1998 to just over 5,100 in 2001. That's a three-year drop of more than 35%.

What is slowing the flow of international graduates? Analysts say that a major factor is the certification process for IMGs. While U.S. medical graduates must take the USMLE Step 1 and 2 exams, foreign-born physicians must also take an English proficiency test and an ECFMG clinical skills assessment that became mandatory in 1998.

Analysts point to the clinical skills test as a major factor in thinning the ranks of international graduates entering American training. The exam, which was designed to test both clinical and communication skills, costs $1,200 and is offered only in Philadelphia. Because some IMGs have problems getting visas to come to the United States to take the exam, the assessment can be an insurmountable hurdle for many.

Faroque A. Khan, MACP, professor of medicine at the State University of New York at Stony Brook and a former College Regent, noted that the exam's price tag would probably have put American training out of his reach if the assessment had been in effect when he was entering residency.

Mohamed S. Siddique, FACP, program director for internal medicine at Wayne State University in Detroit and a frequent lecturer in India, credited the newly-mandated assessment for "a slight trend" among Indian physicians to pursue training in Europe instead of the United States.

And other educators are concerned that the cost and inconvenience of the assessment may be shutting out excellent candidates. "We're losing some outstanding candidates who would have easily passed the exam if it was as readily available as the Step exams," said Herbert S. Diamond, FACP, a member of the resident services committee of the Association of Program Directors in Internal Medicine (APDIM). (The Step exams are offered in 500 centers worldwide.) "The combined costs of travel and the exam fee have made it prohibitive for many people."

Better IMGs

Yet Gerald P. Whelan, MD, ECFMG's vice president of the clinical skills assessment program, defended the additional hurdle, saying that the assessment guards against marked variations in medical training worldwide. He said the exam may also help weed out candidates who are not serious about training in the United States, not proficient in spoken English or whose clinical or communication skills are not up to par.

"More self-selection is going on," Dr. Whelan said about the drop in the number of international applicants for the Step exams and the Match. "That will result in better-qualified candidates, which is good for patients and will ultimately give the whole international graduate community a better reputation."

Other data support Dr. Whelan's claim that the quality of IMG candidates is on the upswing. For instance, USMLE Step 1 pass rates for both U.S.- and non-citizen international graduates taking the exam for the first time are on the rise. In 2000, more than 65% of non-citizen students and graduates passed the USMLE Step 1 exam, a 9% gain from 1997.

Program directors like Wayne State's Dr. Siddique noted that in the past few years, they have begun to see international graduates with USMLE scores in the high 90s.

Some educators, however, point out that higher scores are not necessarily related to the clinical skills assessment. APDIM's Dr. Diamond pointed out that in-service exam scores for international graduates started rising 10 years ago, long before the ECFMG assessment existed.

Immigration issues

The certification process is only one part of the equation. Immigration issues are also shaping how IMGs enter U.S. training programs, and they may affect where they end up in the workforce.

Foreign-born and -trained physicians typically take one of two basic routes to enter U.S. residency training. They can enter a program with a J1 visa, or as a legal immigrant who is a permanent resident.

Once they finish training, J1 visa holders have two options. They can return to their home countries for two years, or they can waive the home residency requirement by finding a job with an employer willing to sponsor a J1 waiver through a state or federal program. (All J1 waiver positions, even those with private employers, must be approved by a federal agency.)

If they take a waiver job, international graduates must typically spend three years practicing primary care in a federally designated underserved area. Once they complete their service commitment, they can apply for a permanent resident visa and look for work elsewhere in the country.

Data show, however, that fewer residents are entering U.S. medicine on a J1 visa. According to the AMA's division of graduate medical education, the number of J1 visa holders fell from 38% of all international graduate residents in 1994-1995 to just 30% in 1999-2000. (While traditionally less than 10% of international graduate trainees have held temporary worker or H1B visas, the number of residents with H1Bs is also falling.) At the same time, the percentage of foreign graduates who were permanent residents rose from 29% to 36%.

The reasons for this shift are varied. Program directors say that they generally prefer candidates with permanent resident visas over temporary visa holders in their programs. Candidates with J1 visas, they say, can run into processing problems in their home countries.

In addition, fewer post-training waiver jobs are available for J1 visa holders now. Analysts say this may discourage some physicians who would have to come on an exchange program visa from even applying. (See "Waiver jobs becoming harder to find" online at heres.)

And immigration into this country has reached its highest level in 70 years, which may mean that more IMGs are part of that immigration wave. Analysts say that many IMGs who are permanent U.S. residents may have immigrated here with their parents or with a spouse who received a temporary visa to work in areas like engineering and computer programming.

George Newman, JD, an immigration attorney with the law firm Blumenfeld, Kaplan & Sandweiss in St. Louis, explained that "growing numbers" of international graduates are also deliberately choosing another route to American training.

Rather than apply straight from medical school, they get a temporary work visa and take jobs in the United States, perhaps doing research with a university or pharmaceutical company. After spending a few years improving their English and getting ECFMG certification, they convert their employment-based visa into a green card and apply to training programs.

Analysts say that for patients, the growing number of IMGs entering training programs as permanent residents is a good thing. "Permanent residents will likely have an easier time working with American patients, greater fluency in English and more mobility in where they can practice," said Kevin Fiscella, MD, an associate professor of family medicine at the University of Rochester School of Medicine and Dentistry in Rochester, N.Y., who has written journal articles about international graduates.

Permanent resident physicians also have many more options once they leave training. Unlike their colleagues with exchange program visas, international graduates with green cards don't have to return to a home country or find a waiver job in an underserved (and underpaid) practice setting. They can pursue subspecialty fellowships without fear that such training will disqualify them for primary care waiver jobs, and they can-like their U.S. medical graduate colleagues-compete for jobs in more desirable settings with better pay.

Workforce implications

Overall, analysts show remarkably little agreement on how changes in the IMG population entering medical training will affect the face of American medicine.

The growing number of IMGs who are permanent residents is "good news if you're one of those people who believe that the United States is going to have a shortage of health professionals," explained Carl J. Getto, MD, dean and provost of Southern Illinois University School of Medicine and chair of the Council on Graduate Medical Education (COGME). COGME advises the federal government on physician workforce and graduate education issues.

In the physician surplus/shortage debate, however, COGME believes the nation faces a physician surplus. In 1996, the council recommended limiting the number of residencies to 110% of the number of graduating U.S. medical seniors. (See the College's position on this issue at www.acponline.org/hpp/pospaper/med_training.htm.) COGME later recommended ending Medicare funding for training J1 visa holders and phasing out the waiver program.

Not surprisingly, Dr. Getto said that the recent drop in the number of entering international graduates with J1 visas makes "a lot of sense." While COGME is now re-evaluating its surplus prediction in light of "anecdotal reports of shortages," particularly in certain subspecialties like anesthesiology and critical care, he said the organization remains committed to "training American graduates as a priority, and American citizens who have been in other countries for medical school."

One problem is that medicine is still a very local phenomenon. Even with a national surplus of physicians-and many analysts disagree that one exists-"you still have many local shortages," explained Thomas R. Konrad, PhD, director of the health professions and primary care program at the Cecil G. Shep Center for Health Services Research at the University of North Carolina in Chapel Hill.

He said that analysts need to assess the physician workforce in terms of geographic and specialty distribution. Looking at geographic needs, Dr. Konrad said, "we still have too few physicians in many poor rural communities," despite the existence of the J1 waiver program and the National Health Service Corps.

Some analysts conclude that more permanent resident IMGs will only contribute to what they call the "maldistribution" of physicians in the United States by lowering the number of physicians available to work in underserved areas and increasing competition for plum jobs in urban and suburban practices.

Edward Salsberg, MPA, director for the Center for Health Workforce Studies at the State University of New York at Albany in Rensselaer, N.Y., said that international graduates who are permanent residents "are going into underserved areas at an even lower rate than U.S. medical graduates. Doing away with temporary visa doctors will cut out the group that is most likely to go" to underserved areas.

Yet according to Stephen S. Mick, PhD, chair of the health administration department at Virginia Commonwealth University in Richmond, Va., international graduates who are permanent residents also serve many "blue-collar, working-class Americans in places like Flint, Mich., Gary, Ind., and Buffalo, N.Y."

And APDIM's Dr. Diamond, who is also program director and chair of medicine at Western Pennsylvania Hospital in Pittsburgh, Pa., pointed out that permanent resident IMGs make up a sizeable number of academic physicians-another type of practice that many U.S. medical graduates shy away from.

"We have produced a number of trainees in our community hospital program who are now on university faculties around the country," Dr. Diamond said. "They now teach in universities that wouldn't have taken them as residents."

Waiver jobs becoming harder to find

While IMGs face new hurdles to enter U.S. medicine, more also find it difficult to remain here by accepting a waiver position.

Several branches of the government, which authorize IMGs to waive their home residency requirement by working in underserved areas, recently reported a drop in the number of available waiver positions.

The Department of Housing and Urban Development disbanded its waiver program several years ago, and waiver approvals at the U.S. Department of Agriculture (USDA)--which administers the waiver program for health professional shortage areas designated by the Department of Health and Human Services--dropped from more than 500 in 1997 to 161 in 2000.

A spokesperson for the USDA program said that decline is due to several factors. First, the government has tightened regulations to guard against waiver-program abuses, improving oversight and restricting the number of waiver requests each employer can make.

But perhaps more importantly, as waiver service requirements increased in the late 1990s from two to three years, there is now less turnover among physicians with J1 waivers in federal and state programs. Some waiver holders put down roots in those communities and choose to stay past their three-year commitment. Five years ago, for example, about 30% of physicians with waivers in Alabama stayed in jobs past their service commitment. Now 50% do.

"That additional year has led some to 'homestead,' maybe start to raise a family or become part of the community," said Charles Lail, rural health programs manager of Alabama's office of primary care and rural health development.

Mr. Lail expects to retain even more foreign-born physicians with waivers because of a new program introduced last year. Physicians with J1 waivers who agree to remain employed in service positions for five years instead of three will be eligible for a streamlined permanent residency process.

And, he said, physician turnover in waiver jobs should also go down as a result of new policies adopted in several states that prohibit international graduates with subspecialty training from applying for primary care waivers.

"We find that subspecialists don't want to continue practicing primary care beyond their service requirement, so we finally rang the death knell on their applying," Mr. Lail said. "We won't consider them if they've had a day of subspecialty training. That's making a big difference."

(The one exception to Alabama's ban on subspecialists for waiver jobs, Mr. Lail said, is geriatricians, who are welcome to apply.)

But Mr. Lail also said he does not expect the lull in J1 waiver sponsorships to continue for long. He noted that many American physicians practicing in rural areas are nearing retirement. "The pipeline may be strong enough to replace physicians in urban areas," he said, "but our rural communities may be in real trouble in the not too distant future."

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