The U.S. Needs More Doctors, and 60,000 May Be Hiding in Plain Sight
Liz Biscevic—New and Improved
When I got the flu earlier this year, I felt like I was dying: Every muscle in my body ached, my head was pounding, and I felt like a parade of elephants was performing a tap dance on my chest. After three days in bed and way too much WebMD, I decided to see a doctor—though that wasn’t as easy as I had expected. I couldn’t get an appointment for the next four days, unless I wanted to drive 45 minutes each way to an urgent care facility. I’m a generally active, healthy 20-something who rarely needs to see a doctor, so finding out how hard it was to make an appointment was disturbing, but it’s a problem many in the U.S. are already familiar with. There simply aren’t enough doctors in America.
The Association of American Medical Colleges projects that by 2025, the U.S. could be short up to 94,700 doctors, with more than a third of the shortfall occurring in primary care. Some, like Indiana University School of Medicine professor Aaron Caroll, argue that the situation is not a shortage but a distribution problem. With too many doctors clustered in cities and taking on lucrative specializations, less populated parts of the country are left with a primary care shortage.
Indeed, rural areas have been hit hardest. “North Dakota has only enough doctors to meet 37 percent of its primary care needs; a mere 30 percent of Missouri’s primary care needs are currently being met,” wrote Dr. G. Richard Olds, former dean of University of California Riverside’s School of Medicine, in The Sacramento Bee late last year.
Reached by phone, Stephen Shaya, a family practice physician and chief medical officer of global healthcare company J&B Medical, ticks off a range of possible solutions, like better utilizing nurse practitioners and physician assistants, as well as technology like telemedicine, so doctors can see more patients in less time. There could also be potential in lowering the high cost of medical school—most MDs graduate with hundreds of thousands of dollars in debt—or offering a faster pathway into the profession for those who choose to work in underserved areas.
While all these ideas have merit, there is already an army of medical professionals waiting in the wings: foreign doctors who are often willing to serve rural communities, but face difficulty getting licensed in America. Jeffrey Gross of the Massachusetts Immigrants and Refugee Advocacy Coalition, and author of “Rx for Strengthening Massachusetts’ Economy and Healthcare System,” said that there could be more than 60,000 doctors living in America who are not licensed to practice here. He asserts that reducing roadblocks for these foreign doctors to practice in the U.S. could make an immediate and significant dent in the ongoing doctor shortage in rural America.
There are already many foreign doctors practicing all over the country, with special visas available to those who received their training here and state programs to place them where they are most needed. But doctors who went to medical school outside the U.S., regardless of experience level and medical knowledge, have to redo some of their training in order to practice in America. All foreign doctors must also prove they speak English, pass the United States Medical Licensing Examination, obtain letters of recommendation from an American hospital or research organization—which usually means working or volunteering at that organization for an extended period of time—and apply for and receive some kind of work visa.
One of the biggest challenges for foreign doctors is getting through an American residency program. All doctors who practice in the U.S. have to participate in a three-year residency in which they work in hospitals and clinics under the supervision of veteran MDs. With 12-hour days and salaries ranging from $40,000 to $65,000, that’s no easy feat. Oftentimes, foreign doctors have to apply more than once before getting accepted, and many have families to support, so low residency salaries are particularly unattractive. “Repeating the residency is not an easy thing, and many times it’s very frustrating,” a Brazilian physician in an American residency program told The Atlantic in 2014. “I do not think the internship will add much to my future career.”
Even for American doctors, it’s increasingly hard to land a residency. While the number of medical students has increased exponentially over the last 20 years, the number of accredited residency programs has not changed since 1997. That means many would-be-doctors end up stuck in limbo. Yes, they’re technically doctors, but they’re unable to take a permanent position until they’ve completed a residency.
The residencies are funded by Medicare to the tune of about $10 billion dollars a year—a number allocated by Congress over 20 years ago that has been frozen since.
In spite of growing numbers of medical school students and the doctor shortage, Medicare maintained responsibility for funding the program. Recently, legislators tried to open up more residencies with the Training Tomorrow’s Doctors Today Act, which would have added 3,000 more spots per year, but the bill was not successful. Without an expansion in the residency program, or a modification making it easier for foreign doctors to practice, it’s unlikely the doctor shortage will truly resolve.
Even so, some Americans argue that lowering the hurdles for foreign doctors might reduce the quality of our nation’s health care. (Nevermind that wealthy Americans often travel to undergo cutting-edge medical treatment not offered in the U.S. and that two of the world’s top three medical schools are outside the U.S.) Frederick Browne, infectious disease specialist and senior management at Griffin Hospital, says the answer is not letting foreign doctors forego the mandatory residency program, even if they have experience and excellent credentials. “I have no concerns about international medical grads coming and helping out,” Browne tells me. “But they still have to go through the same residency programs. … We have a long tradition of medicine in the U.S.” Instead, he favors investing in more medical schools and residencies to fill the void.
Some U.S. medical professionals also worry that an influx of outside doctors would naturally drive demand for their services down and as a result, American physician salaries would decrease. “There’s a lot of people who are concerned about that,” says Shaya. “It’s very expensive to be a doctor. People leave (medical school) with enormous debts.” Despite this concern, MDs are likely among the top 1 percent of earners. If the question is to “have a foreign medical grad with some sort of basic credentials here in the U.S. or have nothing, it’s a no brainer,” Shaya says.
But even if residencies, visas, and licensure became more accessible to foreign MDs, current looming policy battles—like those over the Affordable Care Act and President Donald Trump’s travel ban—could worsen the doctor shortage anyway. The current GOP plan to replace the Affordable Care Act would strip insurance from 24 million Americans if it became law, according to the Congressional Budget Office. Many of those who stand to lose coverage also live in areas with few doctors; so even if there were more doctors in those regions, locals wouldn’t necessarily be able to access them. The immigration ban could also further exacerbate rural America’s health care crisis, since, according to one study, doctors from some of the Muslim-majority countries singled out by the ban tend to reside in states with large swathes of sparsely populated areas like Indiana, Michigan, Pennsylvania, and West Virginia.
Even if Obamacare is not repealed and the travel ban is lifted, the doctor shortage will remain a serious problem. While the United States is taking baby steps to solve the issue by opening more residency programs and encouraging greater acceptance rates at medical schools, lifting barriers and allowing foreign physicians to fill the gaps in health care would create real change now.