Doctor Shortage - Unspoken Health Reform Issue - Widening Access to Doctors Through Internationally Trained Doctors

In an Op-Ed piece in the July 26 Hartford Courant, I wrote:

No matter what the outcome of the debate over health insurance, the next health care crisis will be access to doctors.

The facts are there for all to see:

•A shortage of primary care physicians, in the 50,000 range and estimated to grow to 200,000 by 2019, already exists.

•It takes eight to 12 years to educate and train a primary care physician (family doctors, general internists, geriatricians and pediatricians).

•A Physicians' Foundation survey released in November 2008 of 270,000 primary care physicians, virtually all of those now practicing in the U.S., revealed that 54 percent planned to retire or see fewer patients within the next few years; 60 percent said they would not recommend medicine as a career for their children; and 36 percent said Medicare does provide adequate reimbursement.

•Forty percent of primary care doctors are no longer accepting new Medicare patients; 29 percent of patients are having a hard time finding a primary care doctor who will accept them as patients.

•In Massachusetts, which has achieved near-universal coverage ( less than 2.6 percent uninsured), the waiting time to see physicians in five different specialties is 50 days. For comparison, the wait in days for other cities is Philadelphia 27, Los Angeles 24, Houston 23, Washington 23, San Diego 20, Minneapolis 20, Dallas 19 and New York 19.

Furthermore, in Massachusetts 49 percent of general internists and 95 percent of 270 doctors in teaching hospitals are closed to accepting new patients.

So much for evidence of an impending access crisis, which will almost certainly grow worse as 78 million baby boomers start turning 65 in 2011. As you ponder these figures, keep in mind that Massachusetts and its sister state of Connecticut are among the most affluent in the United States and have much higher numbers of physicians per capita. Massachusetts ranks second with 4.53 doctors per capita, and Connecticut is fifth with 3.68 doctors per capita.

So what is the answer to this impending crisis, which is already upon us, but promises to grow much worse in the immediate future?

Multiple Answers

There are multiple answers – educating more primary care doctors, paying them more, expanding medical schools, introducing more training programs, producing more physician assistants and nurse practitioners, replacing doctor doctors with nurse doctors – but one seldom mentioned is allowing more internationally trained doctors into the U.S.

Yet when I speak to knowledgeable experts and medical educators on how the U.S. is going to fill the doctor gap, invariably they predict the influx of immigrant doctors as the most likely short-term solution.

It is not generally appreciated, but already 200,000 international medical graduates practice in the U.S. They are an indespensible part of our physician workforce. Roughly one-quarter of physicians in active practice are IMGs. In some specialities, they make up 30% or more of active physicians.

Anesthesiology 31%
Cardiology 30%
Internal Medicine 32%
Nephrology 40%
Psychiatry 31%

To become eligible to practice in the U.S, these graduates must pass exams showing equivalent knowledge of US/Canadian medical school graduates, pass English knoewlege tests showing their clinical knowledge and clinical skills, and complete a U.S. based residency programs. Of the 23,000 residents coming out of U.S. Residency programs, 5.0000 are IMGs.

The U.S. is a magnet for doctors educated abroad. We are viewed at the land of opportunity, and we have higher pay and often more prestige than in their native countries. Since 2006, thousands of Cuban-trained doctors are migrated to the U.S., mostly to South Florida.

According to the August 3 New York Times,"Doctors in Cuba Start Over in the U.S.

While the rest of the country is suffering from a shortage of primary care physicians, Miami is awash with Cuban doctors who have defected in recent years. By some estimates, 6,000 medical professionals, many of them physicians, have left Cuba in the last six years.

Cuban doctors have been fleeing to South Florida since Fidel Castro seized power in 1959, but the pace intensified after 2006, when the Department of Homeland Security began a program that allowed Cuban medical personnel “who study or work in a third country under the direction of the Cuban government” to travel to the United States legally. The program has effectively turned a crowning achievement of Cuba’s foreign policy on its head.

Yet for many Cuban doctors, who earn the equivalent of $25 a month, the lure of a life of freedom and opportunities in the United States is too strong to resist. And so these children of the revolution, educated by a Communist regime to reject capitalism and embrace socialism, have ended up in Miami, often tending to elderly Cubans who fled the island before the doctors were born.

I am not advocating immigration of foreign-trained doctors as a solution to our doctor shortage programs. This immigration has its controversial aspects – language barriers between America patients and immigrant doctors, perceptions that these doctors are not as well-trained as American physicians, robbing other countries of badly needed professionals,

But physician immigration is already a big factor in American health care and it should be taken into account in addressing the looming U.S. physician shortage.