By Lucy Berrington, MS
After successful advocacy by stakeholders including the MMS, a new state commission in Massachusetts aims to examine the obstacles facing physicians born or trained outside the US who seek to practice here. Despite many foreign-trained physicians’ proven willingness and ability to work with underserved communities in the US, they face multiple barriers, including a dearth of targeted career services and training programs, complex and costly licensure requirements, and increasing immigration restrictions.
Deeb N. Salem, MD, FACP
Stories about the loss of foreign-trained physicians’ talents have circulated in the US for decades. “I was a medical student at Boston University, on pediatric rotation, at the time when people were fleeing Cuba,” says Deeb N. Salem, MD, FACP, physician-in-chief at the Department of Medicine, Tufts Medical Center. “An older pediatrician had left Cuba with no money, and he couldn’t find work here. He literally ended up sweeping floors in the pediatric section of Boston City Hospital [now Boston Medical Center].”
Such stories persist even in the context of America’s need for physicians to address existing and anticipated shortages in the US. One advocate told Vital Signs of an Iraqi surgeon whose work with the US military made him a target in Iraq for retaliation. He was admitted to the US as a special refugee, but is underemployed despite his many years of medical experience. Physicians mentioned the dearth of residencies for their foreign-trained colleagues, sometimes requiring numerous applications over several years.
According to a 2014 report developed by a statewide task force on immigrant health care professionals, more than 12,000 foreign-born residents of Massachusetts at the time were trained health care professionals; two-thirds of them were educated outside the US. “The path to relicensing for internationally trained healthcare professionals is an especially complex and challenging one,” wrote Jeffrey Gross, PhD, then of the Massachusetts Immigrant and Refugee Advocacy Coalition (MIRA). “More than 1 in 5 foreign-trained healthcare professionals in Massachusetts are unemployed or working in a low wage, low-skilled job.”
Some barriers relate to education and training. All immigrant physicians are required to complete a US residency program and boards regardless of their skill level on arrival. Many talented foreign medical students are competing for increasingly rare hospital observerships that are key to being accepted into a residency program.
Other hurdles may relate to immigration status. Many early-career physicians are chasing a limited supply of visa waivers (see page 2). Chinese and Indian physicians are subject to long visa backlogs and quotas. Increasingly, physicians’ visa applications are questioned by immigration authorities — though when these decisions are challenged by attorneys or litigated in court, they are usually reversed, says Mahsa Khanbabai, an immigration attorney in Greater Boston who routinely works with physicians.
Commission to Reduce Barriers
The new commission in Massachusetts will explore these barriers and recommend solutions. The commission was included in the state budget for the fiscal year 2020, which passed in July; most members will be appointed by the governor.
The experience of foreign-trained physicians necessitates multiple solutions, says Amy Grunder, director of legislative affairs at MIRA. “It’s about a gamut of things, including legislation, support and additional training, systemic blockages, and dedicated residencies for foreign-trained medical professionals in exchange for five years working with underserved communities to help us address clinical shortages.” Some of the potential fixes, she says, are simple and inexpensive, such as online guidance from state licensing boards.
“With the passage of this legislation, Massachusetts has joined a number of other states in beginning to leverage the expertise of immigrant and refugee health professionals to provide care to underserved communities,” says Grunder. The Minnesota’s International Medical Graduate Assistance Program, for example, was established in 2015. Its successes include partnerships with nonprofits to provide career support and with residency directors to help foreign-trained physicians demonstrate clinical expertise. Massachusetts itself has had some success re-credentialing foreign-trained nurses and dentists.
Pathways to Education and Training
Some stakeholders are reconsidering the extreme caution built into the status quo, with its assumption that all foreign-trained physicians must be thoroughly retrained. “If they have the necessary qualifications and experience, maybe they can go through an expedited and vetted process and we can benefit from their skills a lot sooner,” says Alain A. Chaoui, MD, immediate past president of the MMS.
At the Interim Meeting of the American Medical Association, in mid-November, the New England Delegation, led by Massachusetts, will ask the association to study and make recommendations for the best ways of bringing well-trained, competent international physicians into the US workforce. “We would like a study to see how we can evaluate and credential them in a more effective way that is fair to them and also fair to our patients,” says Dr. Chaoui. Such a process would also identify those who need further training.
At Tufts University School of Medicine, meanwhile, Dr. Salem and Dean Harris A. Berman, MD, are exploring the potential for a dedicated training program for immigrant physicians. “We’re interested in figuring out a way to re-educate them and help them find a position that suits their skills,” says Dr. Salem. The program would require a collaboration with BORIM to ensure a path to licensure.
Tufts draws on its experience as a physician recruiter in Chinatown, with its emphasis on cultural competence. “We go out of our way to find Chinese physicians, so our patients feel more comfortable,” says Dr. Salem. His own parents came to the US came from Lebanon and Syria. “My grandmother lived here 50 years and only spoke two words of English. I think about how terrified she was at the hospital where no one spoke Arabic. We are a multicultural city and we need physicians who match our population.”
Physician Immigration Lottery
The immigration barriers have escalated in recent years, says Khanbabai, who chairs the New England chapter of the American Immigration Lawyers Association. For example, physicians seeking visas that will cover their residency are disadvantaged if they come from certain countries, such as those affected by the 2017 travel ban, and may be delayed by the security clearance process.
After completing their residencies, physicians with a J1 visa are obligated to return to their home countries for two years before practicing in the US. Those with an H1 visa, covering six years, hope to find an employer willing to sponsor them for a work visa. “This [federal] administration is scaring employers,” says Khanbabai. “Employers wonder if they should sponsor someone because it may take some effort.”
A network of immigration attorneys and community-based organizations can support physicians encountering visa obstacles. “The system has more hoops to jump through, but it’s still possible. Don’t give up,” says Khanbabai. Community health centers are benefiting tremendously from the J1 visa program, she says, and visa denials are worth challenging. “If the government denies visas incorrectly it’s the role of employers and the community to say, ‘You didn’t follow the law.’ Every time, we find we’re winning when we sue the government about H-1B1 visa denials.”
Rajendra Trivedi, MD, chair of the MMS International Medical Graduates (IMG) Section, introduces immigration attorneys Stephanie Pimentel and Katie Silvia at an IMG reception.
Photo by Doug Bradshaw.
