Future uncertain for internationally trained docs

At a time when primary healthcare in the United States is more dependent than ever on foreign-trained doctors, the programs that permit those doctors to practice in this country face an uncertain future under the Trump administration.

Uncertainty, red tape, and anti-immigration policies have some primary care physicians contemplating leaving the U.S. for more welcoming countries, while some international medical graduates are reconsidering whether they want to practice here.

A decline in the number of international medical graduates would worsen the already serious shortage of primary care doctors, particularly because they tend to choose primary care specialties and many of them work in medically underserved areas.

“We are making healthcare more accessible, but we are subject to such uncertainty that some of us are rethinking whether we have a future here,” says Ram Sanjeev Alur, MD, an Indian-born internist in Marion, Ill., who’s thinking of leaving the country. 

The impact of international medical graduates

According to the American Immigration Council (AIC), just over one-quarter of doctors (247,449) in the U.S. were foreign-trained as of 2017, meaning they received their medical degrees from schools outside the country. A small percentage are U.S. citizens who went abroad to medical school, but most are not.

The percentage of these doctors in primary care is even higher. The same study found that nearly a third (31.8 percent) of physicians specializing in family medicine, internal medicine, or pediatrics are foreign-trained.

International medical graduates are more likely to serve in low-income areas, as well. More than half (53.4 percent) of all such doctors work in areas where the population has a per-capita income of $30,000 or less, according to the AIC. In areas where per-capita income is below $15,000 a year, these graduates account for 42.5 percent of all doctors.

In areas where 75 percent or more of the population is non-white, 36 percent of the doctors are trained outside the U.S. They also make up greater shares of all doctors serving populations with lower educational attainment.

With the Association of American Medical Colleges (AAMC) predicting a shortage of primary care physicians of up to 49,300 by 2030, the AIC and other organizations are raising concerns about the future of primary care.

“International medical graduates serve a very important purpose in providing primary healthcare in this country, particularly in light of the physician shortage,” said Ana Maria Lopez, MD, MPH, FACP, president of the American College of Physicians (ACP). The ACP and other healthcare organizations have lobbied Congress and regulators to ease some policies that made it more difficult for internationally trained physicians to practice here.

One couple's story

The difficulties of those policies are well known to Narayanan Krishnamoorthy, MD, and Chitra Mony, MD, a husband and wife practicing in Tallahassee, Fla. They went to medical school in India, then trained in Scotland.

In 2006, Mony matched with Tallahassee Memorial HealthCare’s residency program. A year later, Krishnamoorthy matched with the same hospital and joined his wife in Florida. Mony, who entered on a national interest visa, was required to work for three years in an underserved area. Krishnamoorthy switched from an H-1B visa, which binds him to one employer, to an H4 visa Employment Authorization Document (EAD) work permit, which allows him more flexibility in working as the spouse of an H-1B visa recipient. They have both applied for green cards to become permanent residents but are in a quota-restricted waiting line that could take decades.

In the meantime, the couple fills multiple gaps in primary care in their community. She is a family practitioner at Tallahassee Memorial. He works four-and-a-half days a week as an internist at a large medical practice while also treating his patients who are admitted to the local hospital and rehabilitation center. He also works half a day a week at a wound treatment center and volunteers to train phy- sician assistants and nurse practitioners, as well as medical students.

The couple have a 13-year- old daughter, who was born in Scotland, and an 8-year-old son, who was born in the United States. They say they want to stay in Tallahassee, but, after 12 years here, their future is still unsettled.
As part of its overhaul of immigration, the Trump administration has announced it intends to end the H4 visa EAD program, which allows H-1B visa spouses, like Krishnamoorthy, to work. He had his H4 visa renewed for three years in April and hopes he will be grandfathered in until 2021 if the program is ended. If not, he would have to apply again for an H-1B visa and return to work for the hospital system or another sponsoring employer.

That could put an end to his practice with the medical group, a practice he says he has built up to 2,000 patients, many of them Medicare recipients who turned to him after two other primary care doctors retired. If that happens, the couple is thinking of relocating to another country with a more welcoming immigration policy for doctors, such as Canada, Australia, or the United Kingdom.

“We are deeply rooted in this community, but what do I say to my 2,000 patients [if I leave]]? I want people to know these things are happening,” Krishnamoorthy says. “We have always played by the rules and done everything right, but we might still have to leave.”

An immigration debate

Most Americans agree that the country needs more international medical graduates, but their fate is tangled up in the larger debate over immigration. Many enter the country on H-1B visas, the same as other highly skilled foreign professionals, particularly IT workers who have drawn the fire of immigration critics.

Bureaucratic restrictions and backlogs have existed for a long time, but critics say it’s gotten worse under President Trump, who has made reducing immigration-legal and illegal-a centerpiece of his administration. Under the Trump administration, H-1B visa approval rates declined from more than 90 percent in fiscal 2017 to less than 85 percent in the first two months of fiscal 2018.
  
U.S. Citizenship and Immigration Services (USCIS) has become more demanding and less responsive to non-native doctors who want to practice in this country, say Jennifer Minear, JD, and Greg Siskind, JD, immigration attorneys who represent such doctors and the U.S. healthcare organizations that want to hire them.

“This is an administration that has a general hostility to immigration, no matter the occupation,” says Siskind. “The overall goal of the administration, I think, is to make the system as unpleasant as possible and try to reduce the number of applicants. I think that is their tactic.”

Minear says USCIS is making it more difficult and time-consuming to renew work visas through “requests for evidence,” demanding proof of everything from doctors’ salaries to their work schedules. From January to November of 2017, USCIS issued around 40 percent more requests than in all of 2016. Minear says USCIS has even challenged whether physicians meet the H-1B requirement that they be “highly skilled.”

“How anyone can assert that a job as a physician doesn’t require a college degree, I don’t know,” she says. “It’s almost like there’s been some sort of internal decision to deny those claims.”

The delays and increased scrutiny are difficult and expensive for the healthcare systems and practices that want to hire the doctors, Siskind says. Uncertainty over when a visa will be approved makes it hard for employers to know when an international medical graduate can be added to a rotation, he says. While visas are eventually renewed, it’s taking its toll. “There are doctors asking themselves whether the U.S. is a good long-term bet,” he says.

In June, the U.S. Supreme Court upheld the administration’s travel ban, which severely restricts immigration from Iran, Libya, North Korea, Somalia, Syria, Venezuela, and Yemen. This policy could worsen the shortage of doctors.

According to the Immigrant Doctors Project, which opposes the travel ban, there are more than 7,000 doctors from the targeted countries practicing in the U.S. The travel restrictions will make it harder for physicians from those countries to work here and could impose hardships on those already here who will not risk traveling home for fear of not being able to return.

State programs 

Some states have stopped waiting for the government to act and started their own programs to make it easier to practice within their borders.

The Minnesota Department of Health’s Office of Rural Health and Primary Care in 2015 began its own program to help offset a projected shortage of 2,000 primary care physicians by 2025. So far, the initiative has funded six residency programs for non-native doctors with the requirement that they practice in underserved areas for five years after graduation.

“We really need (international medical graduates) to provide primary care and we need primary care,” says Yende Anderson, JD, head of the program.

Funding two residencies a year isn’t making a dent in the need, Anderson says, so she is trying to raise $3 million to $4 million a year from foundations and corporations to pay for 10 residencies annually.

UCLA has a program specifically for graduates of medical schools in Latin America. It allows qualified graduates who legally reside in the United States to get the same hands-on training with California physicians as UCLA medical school students.

More programs like that are needed to bring in Hispanic physicians, says Elena Rios, MD, MSPH, FACP, president of the National Hispanic Medical Association. Immigrant Hispanic communities are more likely to trust and seek treatment from doctors of similar backgrounds, she says.

“When people get sick, they want to be treated by someone they’re comfortable with, someone who speaks Spanish,” she says.

Pushing back

As the primary care shortage worsens, healthcare organizations are calling for reform, but so far, progress has largely been limited to fighting to keep a faulty system from getting worse. For example, the AAMC, ACP, and other groups in June persuaded USCIS to reverse its decision to no longer accept AAMC resident stipend data for prevailing wage information on H1-B visas. That had resulted in the denials of visa requests from IMGs scheduled to begin work in residency programs July 1.

Some Indian-born physicians have formed Physicians for American Health Care Access to advocate that Congress create a separate path for doctors to obtain green cards. They also want reform of the rule that says no more than 7 percent of H-1B visas may be issued to natives of any one country in a year. That quota is largely responsible for the backlog of physicians from India, which accounts for more applicants than any other country.

One of the group’s founders is Alur, an internist at Marion Veterans Affairs Medical Center in southern Illinois. He has to renew his H-1B visa every three years and faces a decades-long wait for a green card. “I’m 42,” he says. “I can’t be doing this is my fifties and sixties. If things don’t go right then my job is in peril and my life here is in peril.”