Recruitment of foreign physicians: a zero-sum equation?
Medical school enrollments have increased somewhat in recent years in an attempt to address the physician shortage, but they are relatively minor increases in relation to the projected need. In 2006, the Association of American Medical Colleges (AAMC) called for a 30 percent increase in enrollment by 2015 – or 5,000 new M.D. students annually. Between 2006 and 2010, enrollment increased by only 7.5 percent. At that rate, medical school enrollments will fall far short of the AAMC’s goal.
A dramatic increase in the number of medical schools — an increase that would allow both new and existing residency slots to be filled by U.S. medical graduates — would not be unprecedented, however. As Remapping Debate recently reported, in the 1960s and ‘70s, enrollment at U.S. medical schools more than doubled in response to projections of a physician shortage. This expansion was largely due to funding from the 1963 Health Professions Education Assistance Act, which provided grants for the construction of new facilities and the expansion of existing schools.
Additionally, Tulenko said, “There is already a surplus of qualified applicants [from the U.S], who are going to medical schools abroad, mostly in the Caribbean.”
A substitute for long-term policy?
Some worry that increasing the reliance on foreign medical graduates would distract from the pressing need to increase domestic medical school enrollment. Fitzhugh Mullan, a professor of health policy at George Washington University, has argued that, without IMGs, the U.S. would already have faced a substantial physician shortage.
The U.S.’s reliance on foreign physicians exemplifies the fact that short-term policy to address immediate needs can often end up becoming long-term policy, and even substitute for a more comprehensive approach.
When the number of residency programs in the U.S. was increased in the 1960’s and ‘70s, the number of foreign medical graduates skyrocketed, despite the large increase in domestic medical school enrollment. But medical school enrollment flattened out in the 1980s, despite calls for decreasing the reliance on foreign physicians.
According to Mullan, reliance on foreign medical school graduates was supposed to be a temporary solution, but U.S. medical school enrollments were never increased substantially past the level they reached in the early 1980s and, in effect, reliance on foreign medical graduates has became long-term policy.
Bourgeault said that further increasing U.S. reliance on foreign physicians now has the same risk.
“I think it’s a short-term ‘solution,’” she said, qualifying the word solution because she was not sure that it really solved more problems than it caused. She argued that, with the political will, a wealthy country like the U.S. should be able to train enough of its own physicians to meet its needs.
Aren’t these some of the “good jobs” the U.S. economy needs?
To Edward Salsberg of the Health Resources and Services Administration, proposals to rely more heavily on foreign physicians to meet U.S. healthcare needs seem ironic when viewed in the context of the current labor market.
“There are a lot of people out of work right now, and these are really wonderful careers that pay well and provide opportunities to help others,” he said. “Plus, these are jobs that Americans want. We have to ensure that there is adequate educational capacity for them.”
Rebecca Givan, assistant professor at Cornell’s School of Industrial Labor Relations, agreed, and added that “The government could be much more active” in providing that educational capacity.
“It isn’t so much a matter of capacity, as a matter of political priorities,” she said.
Givan advocates a multi-prong approach, in which the government would adopt policies to recruit and educate Americans who want to become physicians, and then to retain them once they do.
To attract more people into medicine, she said, the U.S. could adopt policies that increase medical training in preparatory school, and possibly even change some of the requirements for admission into medical school to emphasize different skills sets and areas of study, like liberal arts or the humanities. In order to retain physicians, Givan believes that pay for primary care doctors should be increased, and, if possible, workload should be decreased.
Gary Fields, another labor economist at Cornell, took the argument a step further.
“When looking at the issue globally,” he said, “I think the best policy would be to increase the number of highly qualified, well-trained doctors in the U.S., while simultaneously using our immigration policies to allow foreign doctors to receive high quality training here and then return to their countries to deliver care to those populations.”
The U.S. currently grants many graduates of foreign medical schools a J-1 visa, which allows them to do medical residency training in the U.S., but then requires them to return to their home country for at least two years before applying to become a permanent U.S. resident. Through various government programs, however, that requirement is often waived, and foreign physicians are usually allowed to practice in the U.S. after completing their medical residencies.
If domestic medical school enrollment were increased to reduce U.S. dependency on foreign doctors, Fields said, “We could then use our immigration policy to address the global health workforce crisis.”