As a stranger in a strange land – a white, native Californian doing an internal medicine internship at the mostly black District of Columbia General Hospital in 1972 – I was introduced to the international nature of American medicine.
My first supervising resident was a brilliant and imperious woman from New Delhi. At 22 (two years younger than I), she was a prodigy from accelerated medical education in India. My favorite senior resident that remarkable year was an affable, experienced Greek physician in his mid-thirties, duplicating some of his earlier training as required for licensing of immigrant physicians.
A volatile Brazilian senior resident tried to teach me to budget my time with patients to make time for my (and likely his) much-needed leisure activities. My go-to specialist was an Iranian cardiologist who was beloved by all the resident staff because of his enthusiastic teaching of the physical exam of the heart.
Our head radiologist, a native of China, was a leading innovator in catheter-based vascular imaging. My chief mentor in what was to become my specialty – rheumatology – was an Irish national. And so on. Our potluck parties were celebrations of the best of the world’s regional cuisines, elbowing in on the grits, collards, bacon and sweet potato pie of the Mason-Dixon Line.
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It was an established fact then that big-city public hospitals – even those with longstanding medical school affiliations – could not fill their residency positions without recruiting foreign medical graduates. But this axiom missed a key point: the growing output of America’s medical schools was inadequate to meet unanticipated growth in demand for medical services.
Foreign physicians were not doing residencies here and returning home. They were staying to provide needed services. Most were becoming U.S. citizens.
At the medical school, residency and fellowship levels, the American medical-training system, since the Medicare and Medicaid programs of the mid-60s, has failed to provide adequate physician manpower. U.S. funding of medical education is, sadly, terribly uncoordinated.
Equally important, the projection of health manpower needs has been afflicted with overly optimistic views of a positive impact from computerization, improved health care technologies and organizational innovation. It takes nearly 20 years to realize increased manpower from medical school expansions, which are slow and expensive, just like medical education and training itself.
Absent an unprecedented spurt of federal funding for medical training, the American Association of Medical Colleges (AAMC) is projecting a deficit of about 50,000 doctors by 2025. This is a 6 percent deficit in a country with one of the lowest doctor-to-patient ratios in the industrialized world.
So the United States is lucky that we can steal high-quality medical graduates from countries that would love to keep them.
In the 40 years I have taught medicine at the residency programs of University of California, San Francisco-Fresno, I have seen waves of immigration supplying our residency staff – continuously and dominantly from South Asia, but also from the Arabic-speaking countries, Iran, Africa, Eastern Europe after the end of the Cold War, and later Russia.
These immigrants have surmounted imposing obstacles of language, cultural barriers, background checks and extremely high expectations of written-test performance to qualify for residency positions. Scientific studies have shown that their performance in residencies is equivalent to their U.S.-educated counterparts.
Twenty-five percent of the members of the Fresno-Madera Medical Society are foreign medical graduates – similar to the national average. This probably underestimates the contribution of foreigners to the Central Valley’s health care portfolio, since more foreigners practice in rural and underserved areas and are less likely to join the medical society.
Further long-term restrictions on immigration pose a genuine threat to the integrity of our local and national health care services. But even short-term actions like the Trump immigration ban have hazardous consequences.
According to Dr. Darrell Kirch, president of the AAMC, “with Match Day approaching on March 17 (the day on which the computer matching of residency candidates with residency programs is announced), an estimated 1,000 foreign medical graduates from the seven countries named in the executive order have already applied for residency programs and fellowships in the United States.
“These programs are now going through the process of selecting qualified applicants, and the executive order has created confusion around whether these learners will be able to come to this country for training.”
Let’s hope this is not just the beginning of a self-destructive nationalism that further weakens our overtaxed health care workforce.
Dr. Richard Bertken is a clinical professor of medicine at University of California San Francisco-Fresno. Connect with him at firstname.lastname@example.org.