International Medical Graduates Key to Solving the Physician Shortage

The good news about the physician shortage is that government leaders and academic experts finally agree that there is one.

For years, most policy makers and academics took the opposite view, arguing that the United States had too many physicians and that a limit should be put on the number of doctors being trained. Their arguments prevailed, and in 1997 Congress capped Medicare funding of physician graduate medical education. The number of physicians trained in the United States each year has been virtually frozen at about 24,000 since.

The pendulum has finally swung the other way, however, and the majority of experts now concede that there is a dearth of doctors, particularly in primary care. The Association of American Medical Colleges, for example, projects a deficit of 159,000 physicians by 2025. At least 15 medical specialty societies have released studies projecting shortages in their fields. The Lewin Group, a research company based in Washington, D.C., projects that universal coverage would drive the need for 35,000 additional physicians.

The Obama administration has clearly signaled that it understands more physicians will be needed in order to deliver on the promise of expanded access to healthcare.

To date, some action has been taken to increase physician supply. The Obama administration has earmarked $200 million in federal stimulus money to boost the ranks of the National Health Services Corps by 3,300 physicians and other clinicians. It also has reiterated the need to restructure physician reimbursement to more robustly reward primary care physicians for their role in managing care and implementing preventive services. There is also hope that new practice and reimbursement structures, like the medical home, will reignite medical student interest in primary care.

However, the surest way to make a real dent in the shortage is to lift the cap on Medicare funding of medical residency programs. Several bills have been introduced to Congress that would do so, including one submitted by Senator Bill Nelson (D-FL) and Congressman Joseph Crowley (D-NY) that would increase residency slots by 15%.

This would come at a cost of several billion dollars a year—not a significant part of Medicare's overall budget, but possibly prohibitive given current federal budget constraints. So far, none of the bills aimed at increasing physician supply appear to have gained traction, and it is far from clear whether or not residency programs will be expanded anytime soon.

What is clear is that the physician shortage would be considerably worse without the presence in this country of tens of thousands of international medical graduates (IMGs). Foreign-born graduates of international medical schools now comprise about 20% of all physicians in active patient care in the United States. In some specialties, such as cardiology, internal medicine, psychiatry, and nephrology, they comprise 30% or more of all active physicians.

About 6,000 IMGs complete residency training in the United States each year. Many of them remain here, often practicing in underserved areas to meet visa requirements. Others would like to stay but eventually practice elsewhere due to annual visa quotas and other immigration restrictions. These quotas and restrictions should be removed to ensure that any physician trained and qualified to practice medicine in the United States. has the option of doing so.

Unfortunately, this in itself will not solve the physician supply problem. It is time to consider opening U.S. medical practice to physicians who have trained elsewhere. Today, only physicians trained in Canada are permitted to obtain a medical license in the United States without completing a U.S.-based residency program. Canada's medical licensing exam and residency training programs are deemed to be equivalent to those in the United States. Physicians trained in every other country must complete a U.S.-based residency program to qualify for a medical license.

In the past, this policy has been a safeguard that has helped ensure a high standard of care. Today, however, there are thousands of highly-trained physicians from Europe, Asia, and elsewhere who, on a case-by-case basis, have the skills and commitment to contribute to the quality of care available in this country. In fact, a growing number of patients from the United States are traveling abroad to receive care from these doctors. This trend is likely to accelerate as the physician shortage makes access to doctors in the United States increasingly problematic.

It makes little sense to lose these patients or the care and innovation that select international medical graduates could provide. Can it be possible that only physicians trained in the United States and Canada have the skills to provide quality patient care? The time to seriously rethink this notion has arrived.