Pulse
Are We Outsourcing Family Medicine?
In the future, U.S. patients will have about a fifty-fifty chance of being cared for by a family physician from abroad—that is, if residency matches continue to shake out like this year’s.
The face of family medicine is changing in St. Cloud. This year for only the second time, all four slots in the St. Cloud Hospital/Mayo Family Practice Residency Program will be filled by graduates of foreign medical schools.
The St. Cloud program is like many in the United States that are increasingly relying on foreigners who graduate from international medical schools, U.S. citizens who graduate from foreign medical schools, and doctors of osteopathy to fill family residency positions because of a lack of interest among graduates of U.S. medical schools.
The St. Cloud program was launched in 1996, when medical student interest in family medicine was at a high mark. At the time, 73 percent of the 3,167 positions offered nationally were being filled by graduates of U.S. schools. In the 2006 match, U.S. graduates filled 42 percent of the 2,727 spots offered.
That percentage rose for the first time in 10 years, and this year, the University of Minnesota’s six affiliated family practice residencies saw 65 percent of their 40 open positions filled with U.S. grads, according to Macaran Baird, M.D., head of the University of Minnesota’s Department of Family Medicine and Community Health. The statewide average for family residency slots being filled by graduates of U.S. schools also was about two-thirds.
Those numbers don’t necessarily spell good news for family medicine. Residency program directors around the country credit the increased percentage of slots filled by graduates of U.S. schools to the fact that residency programs have cut positions. Minnesota residency programs, for example, offered 16 fewer spots this year. One program at Regions Hospital closed in 2005, and fewer spots were offered at the University of Minnesota Medical Center, Fairview. The Regions program closed because of declining patient revenues; it had also failed to attract a U.S. medical school graduate for several years.
Assessing the Impact
The reasons why U.S. medical school graduates are shying away from primary care are well-known. Regular hours, less call duty, and higher salaries are what attract them to specialties such as dermatology, which filled its slots with 93 percent U.S. medical school grads, otolaryngology (92 percent), and orthopedic surgery (90 percent). What is not known is what effect, if any, relying on international medical graduates will have on the specialty and on patient care.
“It is not unlike the whole immigrant situation; they take the jobs that no one else wants,” says George Schoephoerster, M.D., immediate past president of the Minnesota Academy of Family Physicians and former director of the St. Cloud Hospital/Mayo Family Practice Residency Program. “The question is whether that is good or bad.”
The availability of international medical graduates has allowed residency programs to churn out more family physicians. International medical graduates are included in the match; however, because graduates of U.S. schools typically get preference, graduates of international schools often get placed after the match, when residency programs are trying to fill open slots.
The international graduates who do fill U.S. residencies either are already in the country because of marriage or refugee status, have a temporary exchange visitor (J-1) visa, or are U.S. citizens with degrees from international medical schools.
These graduates tend to choose U.S. residencies because they are likely to receive a higher level of training than they would at home and because it opens the door to practicing medicine in the United States.
The fact remains that without international graduates to step into family medicine and internal medicine slots (56 percent of which are filled with U.S. medical school grads), the United States might experience the same kind of shortage of primary care doctors it did in the 1960s, according to Baird. And that could lead to worse care for patients.
A study of Medicare patients published in Health Affairs in March 2005 found that states with a higher proportion of primary care verses specialty physicians have lower mortality rates and a measurably higher quality of care for a lower cost.
Training physicians from other countries might benefit the state’s immigrant communities by providing them with physicians who can better understand their cultures and experience. However, reliance on international medical graduates can have some downsides.
“If that new arrival trainee doesn’t understand the culture that he is working in, that can be a potential challenge for patients who really want to know that their physician understands them,” Baird says.
It can also be a challenge for colleagues. Schoephoerster remembers a resident from an African country who was steeped in the authoritarian doctoring style one might have found in the United States in the 1950s. Mentors had to help that resident adopt a more cooperative approach to working with staff and patients.
“We want to be respectful of all people no matter what country they’re from, but it is challenging because we want the diversity. But on the other hand, we want a positive diversity, not default diversity,” Baird says.
Finding the Right Match
Despite the fact that residency programs prefer U.S. medical school grads, some Minnesota physicians say it is not because the directors of those programs think foreign candidates make worse doctors. “It’s not an automatic that an international graduate is less desirable than a U.S. graduate, quite the contrary in many instances,” Baird says.
But judging the quality of international medical schools is a tough challenge for residency program staff in the United States. Unlike U.S. schools, which are accredited by the Liaison Committee on Medical Education, international schools are not accredited by a single agency and do not share a common curriculum. Also, deans of U.S. medical schools provide letters of recommendation that describe an applicant’s training and performance; deans of international schools rarely do that.
Schoephoerster says the St. Cloud Hospital residency program seeks international graduates who have had clinical experience in the United States, so they can select the cream of the crop and avoid a having to scramble to fill positions afterward. In addition, many of the residents have had extensive experience practicing medicine in their home countries, Schoephoerster says. For example, one resident was a surgeon in his homeland. “Technically, we didn’t have to teach him how to be a doctor, we had to teach him how to be a doctor in the U.S. system,” he says.
Although all four residents who were selected by the St. Cloud program during the 2006 match are graduates of international schools, three are U.S. citizens.
Contributing to “Brain Drain”?
Schoephoerster says his primary concern about relying on foreign graduates is that some day the well may run dry. “I just assume we can’t steal doctors from other countries forever,” he says. Schoephoerster is also worried that the United States may be hurting patients in other countries by causing a “brain drain” of qualified physicians.
Baird says his primary concern is the inability to attract graduates of U.S. schools to primary care. And he worries that family medicine might reach a tipping point, where U.S. medical students will start to avoid the specialty because they see it as being exclusively filled with international graduates and fear they might not fit in.
To prevent that from happening, Baird believes medical schools have to get students excited about primary care careers early on. One way the university is doing that is through the Rural Physician Associate Program, which exposes third-year students to rural primary care practices. Forty-seven students will participate in the program this fall, compared with 30 last year.
In addition, he says, the university is trying to offer more research opportunities in family medicine to faculty and residents, which some doctors-in-training see as an appealing career choice.
Finally, Baird believes the declining interest in primary care among U.S. medical school grads could be part of a natural cycle: “There is a waxing and waning of things in all fields. A few years ago there was difficulty recruiting people in anesthesia and that’s gone back again.”
But if not, Minnesotans will see a greater proportion of family doctors hailing from India, the Philippines, Pakistan, and Canada—the four biggest exporters of medical graduates to this country.—Scott D. Smith