Recruitment of foreign physicians: a zero-sum equation?
March 9, 2011 — The United States relies heavily on foreign physicians to supply health care to Americans, especially when it comes to providing primary care. Foreign physicians are also concentrated in underserved communities. For several decades, there have not been enough U.S. medical school graduates to fill the slots available in domestic residency programs, and those that are left over go to international medical graduates, or IMGs. In 2010, for example, more than 20 percent of graduates who were matched to first-year residency positions had graduated from foreign schools.
Confronting the Doctor Shortage
This is the third in a series of articles that examine the intensifying shortage of doctors in the United States.
With an intensification of the U.S. doctor shortage looming, one suggested stopgap is to increase the U.S.’s reliance on foreign physicians. The proposal takes two basic forms. Some advocate for “passive recruitment” — a policy under which the number of funded slots at U.S. residency programs would be increased and those additional slots filled, at least in the short-term, with graduates of foreign medical schools. This increase should come hand-in-hand with the relaxation or elimination of current restrictions and bureaucratic regulations on foreign physicians, proponents argue, thereby making it easier for foreign physicians to stay and practice in the U.S. after they have completed their residency programs here.
A more radical proposal, known as "active recruitment," is to lift altogether the current requirement that any foreign physician who wishes to obtain a license to practice medicine in the U.S. complete a residency program here. Several other countries, including Canada and the United Kingdom, engage in active recruitment to address their own physician shortages, or have in the past.
The proposals raise questions about how best to deal with the fact that standards for both medical school education and residency training vary from country to country; the fact that relaxations on limitations of IMGs would not increase the number of doctors in the pipeline if the existing cap on the number of funded residencies weren’t lifted; or the fact that attracting foreign doctors to the U.S. would exacerbate doctor shortages in other countries.
The proposals also have to contend with another frequently observed phenomenon: the tendency of solutions that are touted as “temporary” to harden into permanent arrangements. Would either passive or active recruitment have the perverse effect of stymieing efforts to increase the number of U.S. medical school graduates, or mean that the “zero sum” problem of shifting doctors from other countries to the U.S. would be ignored over the long term?
Currently, in order to obtain a license to practice medicine in the U.S., all foreign medical school graduates are required to complete a medical residency program of at least three years in the U.S. But Richard Cooper, former dean of the Medical College of Wisconsin, suggested that, in order to alleviate the physician shortage here, the U.S. should pursue a strategy of active recruitment of physicians abroad, in which the requirement to complete residency training in the U.S. is waived for qualified doctors.
“The United States is the only country in the world that requires foreign medical students to do their residencies here before they can practice,” he said.
According to Ivy Lynn Bourgeault, professor of health sciences at the University of Ottawa, Canada currently allows foreign doctors to practice through two channels. One is similar to the model used in the U.S., where IMGs come to do residency training here and can thereafter be certified to practice. The other involves active recruitment by understaffed hospitals, health centers or communities of foreign physicians, who are then granted a provisional license.
The United Kingdom aggressively pursued a similar policy in the past, recruiting extensively from other Commonwealth countries like India and South Africa.
“It would be fast, almost immediate, and it would be cheap, too,” Cooper said.
Opponents, such as Edward Salsberg, director of the National Center for Workforce Analysis, which is housed in the Department of Health and Human Services, argue that the requirement that foreign graduates complete residency training in the U.S. is the foremost safeguard for ensuring quality of care.
“We have some of the highest standards in the world, and it’s in everybody’s interest that they be maintained,” he said.
But Daniel Purdom, a family practitioner in Kansas City, argued that requiring that IMGs complete medical residency programs in the U.S. is not the only way to ensure quality. One option, he said, would be for the U.S. to impose qualification requirements on individual physicians, based on competency and language tests, like Canada does (see sidebar).
The canadian model
Foreign physicians actively recruited by Canadian communities or hospitals are required to complete several steps before they are deemed “practice ready.” The exact requirements vary province-to-province, but in general, applicants must first pass a series of examinations, administered by the Medical Council of Canada, designed to test their medical capability through both multiple-choice tests and clinical skills examinations that use actors playing the role of patients.
Applicants must also demonstrate their competency in English (or French, depending on the province).
If these requirements are fulfilled, applicants may be given a “conditional license” and allowed to practice under the close supervision of a licensed physician for six months to two years, depending on the province (some provinces do not grant conditional licenses at all).
Only after this period can a foreign physician that has not completed a residency program in the U.S. or Canada apply for a license to practice independently in Canada.
Salsberg argued that this wouldn’t go far enough to ensure quality.
“In general, we don’t think that just passing a test is going to [provide] sufficient confidence of the qualifications of the individual physicians,” he said.
Another way to assure physician quality, Purdom said, would be to allow a U.S. organization — most likely the Accreditation Council for Graduate Medical Education, which is responsible for certifying U.S. programs — to certify residency programs in other countries.
"That certainly would give more comfort,” Salsberg agreed. “That would have to be looked at.”
But Salsberg pointed out that the requirements of residency programs in other countries vary substantially. Some countries from which the U.S. currently accepts physicians — particularly African countries — don’t even require residency training, he said, and others in Europe, Asia and South America require only two years.
“It isn’t necessarily in the interest of these programs to change their requirements to meet U.S. standards,” he said, which means that, before approving other programs, the U.S. would have to determine which ones come close enough to U.S. standards to qualify for certification.
Salsberg admitted that there are likely several foreign residency programs suitable for evalution by U.S. standards, particularly in Europe, but narrowing the pool to those programs could significantly limit the numbers of new physicians that could be recruited to the U.S. through this proposal, he said.
Purdom argued that every state is already responsible for setting the standards a physician must meet to obtain a license to practice in that state.