The pandemic highlights licensing barriers that predate covid, but many believe it can serve as a wake-up call for state legislatures to address the issue for this crisis and beyond.
This article was published on Monday, January 25, 2021 in Kaiser Health News.
As hospitals nationwide struggle with the latest covid-19 surge, it's not so much beds or ventilators in short supply. It's the people to care for the sick.
Yet a large, highly skilled workforce of foreign-educated doctors, nurses and other health practitioners is going largely untapped due to licensing and credentialing barriers. According to the Migration Policy Institute think tank in Washington, D.C., some 165,000 foreign-trained immigrants in the U.S. hold degrees in health-related fields but are unemployed or underemployed in the midst of the health crisis.
Many of these workers have invaluable experience dealing with infectious disease epidemics such as SARS, Ebola or HIV in other countries yet must sit out the covid pandemic.
The pandemic highlights licensing barriers that predate covid, but many believe it can serve as a wake-up call for state legislatures to address the issue for this crisis and beyond. Already, five states — Colorado, Massachusetts, Nevada, New Jersey and New York — have adapted their licensing guidelines to allow foreign-trained health care workers to lend their lifesaving skills amid pandemic-induced staff shortages.
"These really are the cabdrivers, the clerks, the people who walk your dog," said Jina Krause-Vilmar, CEO of Upwardly Global, a nonprofit that helps immigrant professionals enter the U.S. workforce. "They also happen to be doctors and nurses in their home countries, and they're just not able to plug and play into the system as it's set up."
That's left doctors such as Sussy Obando, a 29-year-old from Colombia, jumping through hoops to become physicians in the U.S. In 2013, she graduated after six years of medical school in Colombia, then spent a year treating patients in underserved communities. But when Obando arrived in the U.S., her credentials and experience weren't enough.
While licensure guidelines vary by state, foreign-trained doctors typically must pass a medical licensing exam costing more than $3,500, and then complete at least a year of on-the-job training, known as a residency, in the U.S. For many, including Obando, that means brushing up on their English and learning the relevant medical terminology. She also needed U.S. clinical experience to qualify for a residency, something U.S.-trained doctors achieve through rotations during medical school.
"If you don't know anyone in this field, you have to go door to door to find somebody to give you the opportunity to rotate," Obando said.
She tried emailing Hispanic doctors she found online to ask if she could complete a rotation with one of them. She ended up paying $750 to enter a psychiatry rotation at the University of Texas McGovern Medical School in Houston.
"I tried to go into internal medicine," Obando said. "But because psychiatry was less expensive, I have to go for that."
She also worked for almost a year as a volunteer at Houston's MD Anderson Cancer Center, and is now assisting with clinical trials for covid vaccines at the Texas Center for Drug Development. She's applied for a residency through a national program that matches medical school graduates with residency slots. But it's difficult for foreign-trained physicians to secure a spot, because many are earmarked for U.S. med school graduates. And many residency programs are open only to recent graduates, not those who finished medical school years ago.
"It's competitive for people who trained in the United States to get into a residency program. If you're trained outside the United States, it's even harder," said Jacki Esposito, director of U.S. policy and advocacy for World Education Services, a nonprofit that helps immigrants find jobs in the U.S. and Canada.
That's why states such as Colorado have eased the requirement for a residency during the pandemic. Early on, Colorado officials realized they couldn't license doctors and other health workers because covid lockdowns had canceled required licensing exams. Under an executive order from Democratic Gov. Jared Polis in April, state officials created a temporary licensing program allowing medical school graduates to begin practicing under supervision for six months, and then extended it through June 2021.
Officials created a similar pathway to temporary licensure for foreign medical school graduates who lacked the minimum year of residency.
Colorado also created temporary licenses for foreign-trained nurses, certified nurse's aides, physician assistants and many other health professionals. All of those licenses require supervision from a licensed professional and are valid only as long as the governor's public health emergency declaration remains in effect.
The state relaxed the scope-of-practice rules for those health workers, too, allowing them to perform any task their supervisors assign to them.
"So if you're an occupational therapist, you can give vaccinations as long as they are delegating to you and they're confident you have the skill and knowledge," said Karen McGovern, deputy director of legal affairs for the professions and occupations division at the Colorado Department of Regulatory Agencies. "You can exceed your statutory skill and practice to what needs to be done during the pandemic."
Through mid-December, the state had received 36 applications from foreign-trained doctors seeking temporary licenses, although only one applicant met all the criteria. New Jersey, on the other hand, received more than 1,100 applications for temporary medical licenses last year. (Michigan also issued an executive order allowing temporary licenses, but it was later rescinded.)
Many of the medical professionals stuck on the sidelines have unique skills and experience that would be invaluable during the pandemic. Victor Ladele, 44, finished medical school in Nigeria and treated patients during a drought in Niger in 2005, in the midst of the Darfur genocide in Sudan in 2007 and after a civil war in Liberia in 2010. His family moved to the U.S. a few years later, but Ladele was recruited to help with the Ebola outbreak in West Africa in 2014. What he thought would be a three-month stay turned into a two-year mission.
Now back in Edmond, Oklahoma, working with a U.N. program that helps new business ventures get off the ground, Ladele has found that the challenges of the covid pandemic parallel many of his past experiences. He saw how a program for Ebola contact tracing told people with a cough or fever to call a hotline, which would direct them to a care center. But as soon as the initiative went live, rumors began to spread on social media that European doctors at the care centers were harvesting organs. It took months of outreach to tribal and religious leaders to instill confidence in the system.
He's seen similar misinformation spread about covid and masks.
"If, in Oklahoma, the public health officials had done outreach to all the pastors in the churches and gained their support for masking, would there be more people using masks?" Ladele said.
Ideally, he said, he would like to spend about half his time seeing patients, but the licensing process remains a challenge.
"It's not unsurmountable," he said. But "when I think of all the hurdles to credentialing here, I'm not really sure it's worth the effort."
Upwardly Global helps health professionals navigate that unfamiliar application and credentialing system. Many foreign-trained health workers have never had to write résumés or interview for jobs.
While the pandemic has temporarily eased entry in five states, Krause-Vilmar and others believe it could be a model to address workforce shortages in underserved areas across the country. As of September, the federal Health Resources and Services Administration had designated more than 7,300 health care shortage areas, requiring an additional 15,000 health care practitioners.
"We've had a crisis in access to health care, especially in rural areas, in this country for a long time," she said. "How do we start imagining what that would look like in terms of more permanent licenses for these folks who are helping us recover and rebuild?"
“These really are the cabdrivers, the clerks, the people who walk your dog. They also happen to be doctors and nurses in their home countries, and they're just not able to plug and play into the system as it's set up.”
Jina Krause-Vilmar, CEO, Upwardly Global
Kaiser Health News is a national health policy news service that is part of the nonpartisan Henry J. Kaiser Family Foundation.
Already, five states have adapted their licensing guidelines to allow foreign-trained health care workers to lend their lifesaving skills amid pandemic-induced staff shortages.
While licensure guidelines vary by state, foreign-trained doctors typically must pass a medical licensing exam costing more than $3,500, and then complete at least a year of residency.
That means brushing up on their English and learning the relevant medical terminology. Foreign-trained clinicians also need U.S. clinical experience to qualify for a residency.