BHPR -

Globalization of the physician workforce implies that there are no national or state borders for the practice of medicine--that there exists a single set of requirements to practice medicine and that as a result, physicians meeting those requirements in one state or country could practice in other states or countries without additional requirements. If there were only one license to practice medicine in the world, the physician workforce could move more freely and more efficiently. To the degree that education and training requirements are state- or country-specific, globalization is deterred.

In the United States, the requirements for international medical graduates (IMGs--graduates of foreign medical schools) are standardized and, for the most part, equivalent to the requirements for U.S. medical graduates (USMGs). To become a licensed physician in the U.S., completion of graduate medical education, i.e. medical residency training in an accredited U.S. residency program, is required. Regardless of prior training and experience, IMG physicians wishing to practice in the U.S. are required to complete residency training in the U.S., a significant impediment to globalization of the medical workforce. All physicians-in-training, including IMGs, must pass a prescribed set of educational requirements and examinations prior to entry into U.S. graduate medical education (GME). In addition to the same licensure and examination requirements as USMGs, international medical graduates must also take the Clinical Skills Assessment (CSA) test and an English proficiency test. Currently, the CSA is administered only in Philadelphia. Foreign-trained physicians living in other countries are therefore obliged to obtain a visa to the United States and assume the travel costs of the visit and the exam.

Visa and immigration requirements are further impediments to globalization and the free flow of practicing physicians from country to country. Roughly half of the IMGs that enter medical residency training positions in the United States are on temporary visas. Of the temporary visas, about one-half are on exchange (training program) visitors'status, J-1 visas. Upon completing their residency programs, per the exchange visitor visa, they are required to return to their home country for a period of at least two years or else obtain a waiver. A U.S. waiver of the two-year return home requirement may be granted to an IMG holding a J-1 visa, in return for a minimum three-year commitment to practice in an underserved area. As a consequence, IMGs with visa waivers constitute over half of all underserved area service commitments in the United States. The U.S. in effect depends on IMGs with visa waivers to provide medical care in underserved areas. About 75 percent of the IMGs who receive waivers eventually become U.S. permanent residents.

In the United States, only 10 percent of the physician workforce are underrepresented minorities (African American, Hispanic and Native American), although these groups constitute 30 percent of the U.S. population. In the year 2000 only 2.3% of the IMGs in graduate medical education were Hispanic and only 1.4% were Black (non-Hispanic). In contrast, over 39 percent were Asian/Pacific Islanders, predominantly trainees from India (20 percent), Philippines (11 percent), Pakistan (5 percent) and South Korea (3 percent) and therefore not considered underrepresented minorities.

Telemedicine, the exportation of medical facilities and services, and distance learning have tremendous potential to help globalize the physician workforce and improve access to medical services. Although telemedicine is relatively limited in the United States, a number of commercial enterprises and academic centers in the U.S. are currently in the process of providing such services across a number of industrialized countries and increasingly in low-income countries.

In the late 1700's, the British economist, Adam Smith, in TheWealth of Nations recognized the benefits of willing exchange, whether between two individuals within or between two countries, as beneficial to both the individuals and society. Then, in the early 1800's, David Ricardo demonstrated the principle of comparative advantage. Under comparative advantage, countries are better off if they not only trade with one another but if they plan their production with trading in mind—specializing in the production of goods which they can produce better and/or more cheaply than other countries and then trading with those countries.

In the late 1800's, with industrialization, came the neoclassical revolution in economics. To sum it up, the more capital (tools) a society had, the higher the per capita production and, in turn, the higher the per capita wages. In general, rich countries would be those with the vast accumulations of capital. In the 1920's, the implications for trade of the neoclassical revolution were more clearly identified by two Swedish economists, Heckscher and Ohlin. In essence, the Heckscher-Ohlin factor endowment or factor proportions theory more clearly explains comparative advantage and trade as a function of the supply of various factors of production, including capital.

Physical capital can move relatively easily from one (market-based) country to another. People, however, do not move around as freely as capital. Not only are there legal obstacles to migration, but families tend to be socially and culturally rooted in their country of birth and such attachments can be difficult to overcome. Even language is sometimes a formidable obstacle to migration. Paul Samuelson in the 1950's was able to show that labor mobility is not necessary for the economic benefits of free trade to hold because labor (and therefore labor mobility) is embodied in the trade of goods and services. So, while assuming the mobility of capital, trade, and many other things, Samuelson was able to algebraically demonstrate that through trade, wages and profits would be equalized between the rich and the poor countries with or without labor mobility.

The physician workforce does not fit well into this globalized trade model. First, physician services are difficult to export (and to embody in exports). While some progress has been made in telemedicine, in-person patient contact is thought to be essential for the delivery of most diagnosis and treatment. Further, in most industrialized countries, a country-specific or even state-specific license is required to practice medicine. Thus, for the most part, physicians must physically migrate in order for physician services to flow from countries with low or declining demand for physicians to countries of high or increasing demand.

Second, physician service demand has very different geographic market segments. The physician market for most developed countries is differentiated from other countries by practice requirements. In the United States, for example, some of the requirements to practice medicine can only be met through training and testing in the United States. Similarly, demand for physician services, and in turn wages, are related to the economic development of the country. In developing countries, much lower levels per capita of private or government resources are available to devote to health care, health care infrastructure, positions for physicians, and physician service payments. Thus, the segmented demand for physicians in a developing country will be relatively insensitive to physician supply. If supply were to all but disappear, little increase in physician income may be observed in developing countries. In the United States, there seems to be an insatiable appetite for physicians and health care, as evidenced by the continued per capita growth of physicians in the U.S. relative to countries like India, the Philippines and Pakistan. In 1980 the physicians per 100,000 population ratios for the US, India, Philippines and Pakistan were 180, 40, 10 and 30 respectively. The most recent data available, for the period 1990 to 1998, show the physicians per 100,000 population ratios for the U.S., India, Philippines and Pakistan to be 270, 40, 10 and 60, respectively.

While not the only motivation, people migrate in response to economic incentives; they move from their own country to another where they can command higher wages. The consequences of such migration parallel those of capital movements. In most cases migration is beneficial to world welfare. The migrants’ marginal productive contribution is reflected in the generally higher wages offered in the new country than in the old. In other words, the loss in production to the country from which they depart falls short of the higher income they command in the new country in which they settle, resulting in a net gain to the world as a whole.

When migration takes place in response to economic incentives, it raises the real income of the world as a whole. The developing countries very often cannot productively absorb people who are highly trained, because the absorptive capacity of the economy depends on its level of developments and degree of industrialization. Thus, again, it is not surprising that a large portion of physician migration occurs from developing countries to developed countries.

However, it should be noted that many foreign countries, including developing countries, have invested through their medical school training of the physicians that emigrate. Thus, in the case of physicians migrating from one country to another, it may not simply be a matter of the individual's investment in their medical training. The country of emigration may justifiably demand compensation for the losses it incurs (even when these fall short of the gains in the receiving country). Some countries, for example India, require a bond to be posted by their graduating medical students who go to the United States for graduate (residency) training. If the graduate does not return following training to practice in India for two years, the bond is lost, even if the individual holds a J-1 waiver.

Beyond investment in training, there are additional questions as to the right or wrong of depending on physicians emigrating from developing countries with poor health status and lower life expectancies to supply developed countries with the physicians they need and, at least in the U.S., substantially depending on immigrant physicians to practice in underserved areas.

While a strong case can be made for compensating the countries of emigration for their losses, the world as a whole nearly always benefits from unobstructed migration of trained labor. It rests upon the cherished principles of personal freedom of choice. It has been suggested that there are ethical or moral considerations associated with the willingness of the U.S. to accept physicians from poor countries, but the discussion has never gone much further than that. It seems the basic question is whether an individual's right to succeed according to their skills, abilities, and desire is more basic than a country's right to control an individual's future based on some perceived need for their skills. (This is a different question from whether the U.S. should utilize its abundant resources to assist poor countries through financial support.)

Trade Agreement-Globalization of the Physician Workforce

The growth in free trade agreements has greatly facilitated the free movement of goods and services and to some degree, the migration of labor. Even certain professionals (most notably engineers and architects), through the standardization of education and experience requirements and reciprocity agreements, are moving more freely between countries and licensing systems. In the European Economic Community (EEC), there are clear plans to reduce national certification requirements for physicians and to adopt a uniform European Standard (Mick, et al., 1995). The United States has also taken some steps toward the development of a global market. While a small step, the framework of mutual recognition of professional competency, in place since 1989 under the U.S.-Canada Free-Trade Agreement, and the North American Free Trade Agreement (NAFTA) in 1994 are steps toward free movement of professionals.

The NAFTA agreement provides, in regard to professional service providers including physicians, specific entry rights to certain categories of professionals who meet minimum educational requirements or possess alternative credentials. Under the professional category of NAFTA, each government has agreed to facilitate the temporary entry into its territory of professionals including physicians who are citizens of other NAFTA countries. Physicians will be admitted to the United States under the NAFTA professional category only if they are licensed in their country of citizenship (Mexico and Canada). In order for physicians to practice in the United States, they must, in addition, meet all state licensing requirements in the U.S. However, NAFTA obligates each party, at both the federal and state levels, to eliminate any citizenship or permanent residency requirements to maintain a professional license or certificate.

While the NAFTA agreement encourages reciprocity among the U.S., Canada, and Mexico, some preliminary steps in this direction were taken pre-NAFTA by the U.S. and Canada. Medical schools in Canada and the U.S. are accredited by the same organization, the Liaison Committee on Medical Education (LCME), which effectively ensures that students in both countries receive the same medical education. The result is that Canadian medical graduates can apply and be accepted into a U.S. residency-training program without having to go through the Educational Commission for Foreign Medical Graduates (ECFMG) certification process alluded to in the subsection that follows. Thus, a Canadian graduate could, following a U.S. residency, become licensed to practice in the United States. The individual would still face immigration issues, however.

CURRENT SYSTEM OF GRADUATE MEDICAL EDUCATION AND MEDICAL LICENSING REQUIREMENTS FOR INTERNATIONAL MEDICAL GRADUATES IN THE UNITED STATES

Graduate Medical Education (GME) is clinical training in an accredited residency program following graduation from schools of medicine, osteopathy, dentistry and podiatry. The GME training is required for all medical graduates, including international medical graduates (IMGs), in the U.S. before obtaining medical licensure to practice medicine. Teaching hospitals serve as primary training sites for most residency programs. The number of positions available in any given year depends on a variety of factors, including the amount of funding available to the program and the program's staffing needs. The Accreditation Council for Graduate Medical Education (ACGME) is the body that accredits U.S. graduate medical education programs, i.e. residency training programs. The ACGME has established general requirements for all residencies as well as special requirements for each medical specialty.

To enter graduate medical education programs in the United States, all medical graduates, including IMGs, must pass the United States Medical Licensing Examination (USMLE). The USMLE is a three-step examination: Step 1 tests the medical graduates’ basic science knowledge; Step 2, their clinical knowledge; and Step 3, their competency in patient management and treatment. All medical graduates, including IMGs, must pass the USMLE Steps 1 and 2 before entry into a residency training program and Step 3 during or after completion of the residency.

Every year, there are about 100,000 residents in 8,000 different residency programs. Of the 100,000, on the order of 25,000 are IMGs.

The Educational Commission for Foreign Medical Graduates (ECFMG), through a program of certification, assesses the readiness of IMGs to enter U.S. residency or fellowship programs accredited by ACGME. All IMGs seeking to enter an ACGME-accredited graduate medical education program must have a valid ECFMG certificate. To obtain a certificate, they must take USMLE Steps 1 and 2, as mentioned above, and in addition, must take an English proficiency test and the Clinical Skills Assessment (CSA) test. The CSA examination, which came into effect in 1998, is administered in Philadelphia, thus obliging foreign-trained physicians living in other countries to obtain a visa to the United States and incur the travel costs of the visit and the exam in order to be certified. These two examinations, CSA and English proficiency, are not required of graduates of the Liaison Committee on Medical Education (LCME) accredited medical schools, i.e., USMGs and Canadian medical graduates.

There are no formal restrictions, overall or by program, limiting the number of IMGs that enter ACGME-accredited residency training programs. However, certain specialties and programs within those specialties vary in their competitiveness. ECFMG plays no role in determining the number or mix of positions offered by residency programs or in selecting applicants to fill those positions. All decisions regarding the selection of applicants are made by the Program Directors of the residency programs.

Depending on specialty, most residency programs range from 3-6 years. A resident is prepared to undertake independent medical practice within his or her chosen specialty upon satisfactory completion of a residency. To practice medicine within a particular licensing jurisdiction, individual physicians including IMG physicians must be licensed. The Board of Medical Examiners (or the equivalent) grants medical licenses in each licensing jurisdiction (the 50 states, the District of Columbia, Puerto Rico, and the Virgin Islands). Medical licensing is required for both U.S. medical graduates and international medical graduates in order to practice medicine in the U.S.

According to data from the National Resident Matching Program (NRMP) 2002, ACGME-accredited programs offered 20,606 postgraduate year one (PGY-1) positions. Of the 6,585 IMGs who were active applicants that year, 3,427 or 52% were offered positions whereas of the 16,661 USMG active applicants that year, 14,876 or 89.3% were offered positions (NRMP 2002). While the number of U.S. medical school graduates entering GME each year has remained relatively constant, the number of IMGs entering training has markedly increased, from 12,703 in 1980 to 24,707 in 2000 (AMA Masterfile, 2002-2003).

International medical graduates constitute about 25% of physicians in graduate medical education and an equal percentage of the physician workforce in the United States. Over half of the IMGs in GME are U.S. permanent residents or citizens. Another 43 percent are temporary workers¹. Of the temporary status workers, over one-half are on the J-1 exchange visitor (training) visa. The major categories of citizenship status of IMG resident physicians and their respective percentages in 1998 are illustrated in Figure 1.

The Immigration and Naturalization Service (INS) grants H-1B visas to temporary professional workers who are required to have a prearranged job, either temporary or permanent, in a professional field before they receive a visa. There is an initial admission period of three years, with the possibility of extending the stay for a second three-year period. After staying in the U.S. for the maximum six-year period, a foreign citizen is required to live abroad for one year before re-entering the U.S. on an H visa.

The exchange visitor visa (J-1) has been the most frequently used visa by IMGs for graduate medical education and includes a provision of return to the country of last legal permanent residence for two years after completing GME. The only exception to the two-year home residence requirement of the J-1 visa program is through receipt of a waiver called J-1 Waiver. Most J-1 waivers are requested in the form of sponsorship by an "interested government agency" (IGA). The major sponsoring agencies of J-1 waivers for IMGs and their respective requirements are:

1 Temporary workers include Refugees, Exchange visitors (J-1), Students (F-1) and H-1 visa holders.

In addition, the "Conrad provision" provides for up to 20 J-1 waivers per state per year. Thus, there is a maximum of 1000 Conrad waivers each year. Under the Conrad provision, a state is permitted to sponsor an IMG in return for a 3-year (or more) service commitment. As of 2002, 44 States had a program to request J-1 waivers (Mueller, 2002).

IMGS AND PHYSICIAN SUPPLY, U.S. IMMIGRATION POLICIES, AND SERVICE COMMITMENTS IN UNDERSERVED AREAS

International medical graduates have formed an important part of the U.S. physician workforce of this country since the 1960's. In the early 1960's, IMGs were about 10% (26,048) of the physician workforce; by 1970 that percentage had increased to nearly 18% (57,217). Today, IMGs are about 25% (196,961) of the U.S. physician workforce.

Based on a perceived shortage of physicians in the 1960's and 1970's, IMGs were encouraged through immigration laws to enter the United States and participate in graduate medical education as exchange visitors. These physicians would receive advanced medical education, provide service to the hospitals in which they trained, and return to their countries with the latest U.S. medical training. Domestically, during that period of time, the annual number of U.S. medical school graduates (USMGs) doubled.

The impact of these education and immigration policies has been to double the nation's physician supply. Physician availability as measured by physician-to-population ratio increased by 70% as illustrated in Figure 3.