Why America Needs Foreign Medical Graduates

The following originally appeared on The Upshot (copyright 2017, The New York Times Company).

As our recent eight-nation bracket tournament showed, many people think the United States health care system has a lot of problems. So it seems reasonable to think of policy changes that make things better, not worse. Making it harder for immigrants to come here to practice medicine would fail that test.

The American system relies to a surprising extent on foreign medical graduates, most of whom are citizens of other countries when they arrive. By any objective standard, the United States trains far too few physicians to care for all the patients who need them. We rank toward the bottom of developed nations with respect to medical graduates per population.

When physicians graduate from medical school, they spend a number of years as residents. Although they have their degrees, we still require them to train further in the clinical environment to hone their skills. Residents are more than learners, though; they’re doctors. They fill a vital role in caring for patients in many hospitals across the country. We don’t have enough graduates even to fill residency slots. This means that we are reliant on physicians trained outside the country to fill the gap. A 2015 study found that almost a quarter of residents across all fields, and more than a third of residents in subspecialist programs, were foreign medical graduates.

Leaving training aside, foreign medical graduates are also responsible for a considerable share of physicians practicing independently today. About a quarter of all doctors in the United States are foreign medical graduates.

As in many other fields, foreign medical graduates work in many of the areas that other doctors find less appealing. More than 40 percent of the American primary care work force is made up of people who trained in other countries but moved here. More than half of all the people who focus on caring for older people are foreign medical graduates as well.

As if this weren’t enough, foreign medical graduates are more likely to practice in geographic areas of the country where there are physician shortages (typically nonurban areas), and they’re more likely to treat Medicaid patients.

As a physician who graduated from a domestic medical school, I’ve often heard others disparaging doctors who went to medical school outside the country as if they were inferior. Those complaints are not supported by data. A study from Health Affairs in 2010 found that patients with congestive heart failure or myocardial infarction had lower mortality rates when treated by doctors who were foreign medical graduates. Another from earlier this year in the BMJ found that older patients who were treated by foreign medical graduates had lower mortality as well, even though they seemed to be sicker in general.

recent study in Annals of Internal Medicine shows that these graduates are also responsible for a significant amount of teaching. Of the 80,000 or so academic physicians in the country, more than 18 percent were foreign medical graduates. More than 15 percent of full professors in medical schools in the United States were educated elsewhere, most often in Asia, Western Europe, the Middle East, Latin America and the Caribbean.

Foreign medical graduates also do a lot of research. Although they are ineligible for some National Institutes of Health funding — which is granted only to citizens of this country — they still manage, through collaboration, to be primary investigators on 12.5 percent of grants. They led more than 18 percent of clinical trials in the United States and were responsible for about 18 percent of publications in the medical literature.

“Our findings suggest that, by some metrics, these doctors account for almost one fifth of academic scholarship in the United States,” said the lead author of the study, Dhruv Khullar, who is a physician at NewYork-Presbyterian Hospital, a researcher at Weill Cornell and a contributor to The Upshot. “The diversity of American medicine — and the conversations, ideas and breakthroughs this diversity sparks — may be one reason for our competitiveness as a global leader in biomedical research and innovation.”

The United States is not the only country that relies on doctors trained or educated in other countries. We’re not even the country with the highest percentage of such physicians. According to data from the Organization for Economic Cooperation and Development, almost 58 percent of physicians practicing in Israel are foreign medical graduates. About 40 percent of the doctors in New Zealand and Ireland were trained outside those countries.

Because of the sizes of those nations, even though the percentages of foreign medical graduates are higher there, the total numbers aren’t as high as in the United States. In 2015, the O.E.C.D. estimated that the United States had more than 213,000 foreign-trained doctors, and no other country was close. Britain had about 48,000, Germany had about 35,000, and Australia, France and Canada had between 22,000 and 27,000.

For years, I’ve listened to doctors tell me stories of physicians who leave Canada — because they were dissatisfied about working in a single-payer health care system. That might have been true decades ago. But in the last 10 years, that number has dropped precipitously. The number of Canadians returning to their country to practice may actually be higher than the number leaving.

Although many feared that coverage expansions from the Affordable Care Act might lead to an overwhelmed physician work force, that didn’t happen. That doesn’t mean that America doesn’t have a shortage of physician services, especially when it comes to the care of the oldest, the poorest and the most geographically isolated among us. Even though we know foreign medical graduates care for those patients disproportionately, we make it very difficult for many born and trained elsewhere to practice here. Some Americans need these doctors desperately. Evidence suggests that policies should be made to attract them, not deter them.


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