In A Moveable Feast, Ernest Hemingway details his time in Paris in the 1920s, dedicating a section to his friend F. Scott Fitzgerald. In this part, Gatsby’s creator is depicted as, among other things, a hypochondriac. In one of Fitzgerald’s dramatic fits, he insists on going to the American Hospital in Paris because, “I don’t want a dirty French provincial doctor.”
Nearly 100 years later, the American Hospital in Paris continues to thrive. On its staff are eight American doctors as well as 378 European ones. It is the only hospital in Europe where a doctor can practice with a U.S. medical license. American doctors hoping to work in Europe would normally have to re-do their residencies before practicing independently.
The United States also has strict policies regarding medical licensing—a doctor is only allowed to practice in the U.S. once he has obtained a license in the state in which he intends to work. The person must acquire a visa, pass the first two steps of the United States Medical-Licensing Exam (USMLE), then become certified by the Education Commission for Foreign Medical Graduates (ECFMG), get into an accredited U.S. or Canadian residency program, and finally, go back and pass step three of the USMLE. Each of these steps could take multiple years, repelling doctors who are already able to practice in the country in which they were trained.
But is it really a good idea to deter them? By 2020, America’s doctor shortage is projected to reach 91,500 too few doctors, with nearly half of the burden falling on primary care. This means doctors will be overworked and citizens may have to wait longer and pay higher fees for an appointment.
Without all of these barriers, many foreign doctors would find the prospect of migrating to the United States appealing. Dr. Arun Gadre, an otologist originally trained in India and now practicing at the University of Louisville, explains, “Arguably [the U.S.] is the only country in the world where one can do cutting-edge research, practice cutting-edge medicine, and still make a decent living.”
Dr. Faris Alomran, a British-educated vascular surgeon working in France, says, “My first choice after medical school was to practice in the U.S. In fact, for most [English-speaking] people, in terms of language options, they are somewhat limited to Australia, Canada, and the U.S.”
But he didn’t end up crossing the Atlantic. “In the U.S. I would have had to do five years of general surgery and a two-year fellowship in vascular surgery to be a vascular surgeon. Seven years total. I got an offer in Paris to do a five-year vascular surgery program. They also reduced my training by one year since I had done two years in the U.K.”
Juliana, a physician originally trained in Brazil and currently in an American residency program, agrees that migrating to the U.S. could have been easier, especially if redundant training were removed. “Repeating the residency is not an easy thing, and many times it’s very frustrating. I do not think the internship [that I’m in] will add much to my future career. Having trained in America for the last four months has helped me understand cultural differences [between the U.S. and Brazil], but it has also made me wish I were allowed to skip some steps.”
Though re-doing her residency has been frustrating, it was an achievement to get accepted into a program in the first place. Locking up a coveted residency post is a significant hurdle for foreign-trained doctors. All U.S. states require at least one year of residency in an accredited American or Canadian program to qualify for a medical license. Though the number of students in medical schools has increased, the number of accredited residency positions has remained relatively stagnant since 1997.
American Medical Association President Robert Wah recognizes this residency bottleneck. “U.S. residency program positions have not increased at an adequate rate to accommodate the expanding number of U.S. medical graduates and the current IMG [International Medical Group] applicant pool,” he said in an email.
Even if the AMA were to magically produce a few thousand more residency slots, it would barely make a dent in 91,500 projected doctor shortage.
Whittling down the shortage will likely take a combination of measures. Three-year medical degree programs, reduced from the typical four years, already exist at NYU, Texas Tech, and Mercer. Ohio wants to expand the roles of physician assistants and nurse practitioners, allowing them to take on more of doctors’ responsibilities. Earlier this year, Missouri passed legislation allowing medical school graduates to work as assistant physicians and treat patients in underserved areas, a measure that is controversial because at least one year of residency is usually required to practice independently.
In addition to these strategies, reducing entry barriers for well-trained foreign doctors would be a way to immediately increase the U.S. doctor supply.
Those opposed to reducing entry barriers claim that the U.S. produces the best doctors in the world, and that bringing in more foreign physicians would reduce the quality of the country’s medical care. Gadre agrees that it’s important for the U.S. to maintain its high standards for medical practitioners. “In large countries like India levels of education and competence can vary vastly between the big cities and smaller towns due to a lack of standardization, and sometimes even corruption, in the educational system… So the AMA is correct in ascertaining that certain minimum standards must be maintained ”
However, there are plenty of highly skilled, foreign-trained doctors. Basketball player Kobe Bryant opted to go to Germany to treat his knee. According to Atul Gawande, the best hernia surgeons in the world are at Shouldice Hernia Center in Ontario, Canada. QS, a company that does worldwide university comparisons, ranks Oxford’s and Cambridge’s medical schools second and third in the world, behind Harvard’s and ahead of Stanford’s.
Beyond diluting the quality of medical care, another fear is that more doctors coming to the U.S. would mean fewer talented doctors abroad. The Economist, however, disagrees with this reasoning, arguing that a chance to come to the U.S. would motivate more foreigners to study medicine, and most of them would stay in their home countries.
A third fear is that loosening regulations would negatively affect U.S. medical schools. If coming back to the U.S. were easier, Americans might be more likely to study in places like England and Israel because becoming a doctor would be both cheaper and faster overseas.
Further, an influx of doctors could impact a more sensitive matter—with an increased doctor supply, salaries among America’s white-coats would almost certainly go down.
“Nobody wants to share their pie,” Alomran says. “This is the same everywhere and is not unique to medicine, in my opinion.”
Nonetheless, Wah claims that the AMA supports rule changes that make it easier for foreign doctors to transition to practicing in America as long as the quality of medical care does not suffer. “We [the AMA] support the development and distribution of model legislation to encourage states to amend their Medical Practice Acts to provide that graduates of foreign medical schools meet the same requirements for licensure by endorsement as graduates of accredited U.S. and Canadian schools,” he says.
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