opinion

IMGs: Linchpin to the future of U.S. health care

A message to all physicians from AMA President Ardis Dee Hoven, MD, on the importance of international medical graduates to American medical care.

By Ardis Dee Hoven, MD , an internal medicine and infectious disease specialist in Lexington, Ky., is president of the AMA. She served as chair of the AMA Board of Trustees during 2010-11 Posted July 29, 2013.

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A few weeks ago I was privileged to address the Assn. of Physicians of Pakistani Descent of North America. Actually, the real privilege was the chance to meet and visit with so many dedicated physicians.

That night, I gained much better insight into the contributions that foreign-born and international medical graduates, or IMGs, make in this country and how much we all — physicians and patients — depend on them for the success of our American health care system.

Fully 25% of physicians practicing in the U.S. and 27% of residents and fellows are IMGs. These physicians overwhelmingly are the men and women who provide care in underserved and rural areas and to populations that might not otherwise have access to health care. Our numbers tell us that IMGs tend to practice in areas that have a ratio of fewer than 120 physicians for every 100,000 people and a high percentage of elderly and minority patients. We need them. Badly.

Last year in Chicago, following a talk I gave to a group of physicians from the National Arab American Medical Assn., I was greeted by dozens of IMGs, young men and women who had graduated from medical schools in their home countries but had been unable so far to get into U.S. residency programs. They were working in labs or holding down other medical-related jobs while they continued to apply for residency positions. Year after year. That just blew me away. I knew of the difficulty in securing GME placement but had no idea of the kind of dedication these young people demonstrated.

The GME situation, of course, is one that affects all medical graduates — whether they earned their degrees in the U.S. or elsewhere — a crazy limitation in the face of growing patient need, increases in U.S. medical schools, and the projection that in just four years the U.S. will be short by more than 60,000 physicians.

The AMA has been working hard to alleviate this situation — to increase GME positions across the board to meet the needs of U.S.-trained students as well as to make it easier for IMGs to come to the U.S. The AMA has been pushing Congress to lift the existing GME cap, increase the number of positions, and seek additional sources of funding.

The AMA goal: Add 15,000 primary care, general surgery and other undersupplied specialty residency positions.

This situation, bad as it is for American medical school graduates, is far worse for IMGs.

Many states actually have two different sets of evaluation criteria for granting a license to practice medicine in their states — one for graduates of American medical schools and one for graduates of international schools.

For instance, residency selection programs look for higher USMLE scores from IMGs than U.S. graduates. And certain states will grant U.S. medical graduates their unrestricted medical license after just one year of residency, whereas international medical graduates have to wait up to three years to even apply for their unrestricted license.

A second challenge is the underrepresentation of international medical graduates in leadership positions on state medical boards, RRCs, and specialty boards. These organizations and training programs shape the licensing policies and essentially the futures of the next generation of physicians in this country. IMGs need to be adequately represented in these organizations to make sure they are heard.

The AMA and our IMG Section are also lobbying to alleviate visa complications and delays.

For example, the AMA supports federal legislation that would permanently reauthorize the J-1 visa waiver program; increased transparency in employment contract terms (e.g., contracts would have to list hours and locations of work and could not include a noncompete provision); provide additional waivers per state for academic medical centers; expand the current cap on J-1 visa waivers from 30 positions to 50 positions per state; and exempt physicians-in-training from H-1B caps, which allow U.S. employers to temporarily employ educated foreign workers in specialty occupations.

Of particular interest right now is the AMA work on the immigration bills being so actively debated in Washington, including a bipartisan, comprehensive immigration bill, S. 744, that addresses several physician-related issues and was passed by the Senate on June 27 by a 68-32 vote.

This legislation proposes improvements to the Conrad 30 waiver program and the National Interest Waiver green card program, which allow IMGs with J-1 visas to stay in the U.S. and become eligible for green cards after working for five years in underserved areas or with underserved populations. The legislation also includes other changes to immigration laws that would ease restrictions on IMGs seeking employment and permanent residency in the U.S.

During Judiciary Committee deliberations, the AMA also was involved in convincing legislators to scrap proposed burdensome recruiting and hiring regulations that would have conflicted with the current operations of the Match and would have dissuaded employers from hiring international medical graduates with H-1B visas.

Given the physician work force shortage confronting the nation, the AMA strongly supports these provisions that will allow IMGs to continue providing much-needed health care to patients across the country.

We also expect the U.S. House of Representatives to advance separate immigration-related legislation this year. Rep. Darrell Issa (R, Calif.), along with House Judiciary Chair Bob Goodlatte, (R, Va.), introduced H.R. 2131, the Skills Visa Act, on May 23. As a result of AMA advocacy efforts, this legislation includes many of the same physician-related immigration provisions as the Senate-passed bill. H.R. 2131 was passed out of the House Judiciary Committee on June 27.

I am proud of the work that the AMA is doing on behalf of international medical graduates, and I am proud of the more than 36,000 members of the AMA who are IMGs. They are a vital part of the medical work force, and will only become more important in the years to come.

Ardis Dee Hoven, MD , an internal medicine and infectious disease specialist in Lexington, Ky., is president of the AMA. She served as chair of the AMA Board of Trustees during 2010-11

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