Foreign-born physicians strengthen health care in Minnesota

ST. CLOUD, Minn. (AP) - As a doctor trained in primary care, Ali Hamdan would have been in demand back home.

Hamdan had every intention of returning to his native Lebanon after finishing his residency in primary care and advanced training at the University of Rochester Medical Center, in Rochester, New York, as his J-1 visa required, the St. Cloud Times (https://on.sctimes.com/2s2uvuE ) reported.

But then he found out he was needed here.

After hearing foreign doctors talking about a program that lets them stay in the United States, Hamdan began to reconsider. If he went home, would he be able to practice his specialty of intensive care? What about the adjustment for his wife and his American-born son?

“Putting all this together, maybe this is an area I need to explore,” Hamdan said.

By 2025, the nation could need 35,600 more primary care doctors than it will have. For other specialties, the shortfall could be more than 60,000, according to the Association of American Medical Colleges.

Medical schools in the U.S. are not keeping up with demand. They simply aren’t training enough students. The U.S. is making up the difference with foreign-trained doctors, who are 25 percent of the nation’s doctors.

Central Minnesota is one part of the country that is benefiting from foreign-trained doctors, said Dr. Mark Matthias, vice president of medical affairs and physician vice president of the Acute Care Division at CentraCare Health.

CentraCare employs roughly 120 foreign-trained doctors, which is about 20 percent of its doctor workforce.

“It shows how much we rely on foreign-born physicians,” he said.

He only sees that percentage going up.

“As much as we’re proud of medical education in Minnesota, there are not enough to keep up,” Matthias said.

A J-1 visa is one way doctors can come to the U.S. It carries special criteria, including a requirement that the doctor will practice in areas with a shortage of primary care doctors. By doing so, they can take a faster path to permanent residency in the U.S.

“There is a huge, untapped workforce out there which we could utilize in health care and make our health system better,” said Dr. Sumir Saghal, an Indian-born physician based in the Bronx who advises international medical graduates on how to compete for medical residencies in the United States.

CentraCare’s legal department works with law firms that specialize in certain visas, like the J-1 visa, Matthias said.

“It’s so common that we typically deal with it. It’s just something that is part of the application process,” he said.

It’s easier to obtain work visas as a primary care doctor than as a specialist. Some government groups and states sponsor doctors who will work in primary care.

“The government has to do it,” Dr. Imran Chaudhary agreed. He came to the U.S. on a J-1 visa and now practices cardiology in New York.

“I bet they wouldn’t do it if they had enough U.S. doctors. Almost all small areas would be devastated and would not have enough physicians or very few physicians left if foreign grads stopped coming here,” he said.

Foreign-trained doctors could be seen as the migrant workers of the health care system, practicing in locations and medical fields that others avoid.

“I think it’s fair to say that,” Chaudary said. “I don’t think that migrant workers are in any way lesser or inferior. They’re doing a job that is very, very important, and all jobs are important. In our minds, there are some more desirable and less desirable. But they are all important jobs.”

Unrest in the immigration domain following President Trump’s executive orders banning people from certain countries could impact the foreign-trained-doctor pipeline to underserved U.S. communities. CentraCare hasn’t seen much impact, however.

“But it certainly could, if that pipeline were to change,” Matthias said. “We’re pretty reliant on them. …. Some of the concerns people had about this is how might this affect our ability to get those really brilliant people to come to the United States?”

Chaudhary agreed.

“If you take foreign grads out of the system, the entire physician workforce would be taxed,” he said. “That would affect your local care.”

A gap in primary care can be costly to patients and the health care system. A lack of easy access to preventive care may mean a patient suffers a heart attack, instead of lowering their blood pressure by losing weight, eating better or using medication. It may also mean patients use emergency rooms as their only source of care, which is an expensive way to treat people.

Transportation is a huge issue for many people. Long distances between their homes and their doctors may mean they leave illness untreated.

Not only is the U.S. not producing enough doctors, it’s also facing a high number of retirements that will come as the baby boomers age out of the workforce.

It’s something health care systems, including CentraCare, are already recruiting for, Matthias said.

“How can we have enough people situated to take care of that demand?” Matthias said. “Every health care system … is paying attention to that.”

It can be more common to see foreign-trained doctors in primary care because of visa restrictions. But some do work in specialty care.

At CentraCare, foreign-trained doctors are well represented as cardiologists and as hospitalists in internal medicine, who work with complex, critical cases only in the hospital.

Doctors who attend medical school in another country but do their medical residency in the U.S. are attractive hires for many health systems, Matthias said.

“They pass the same tests as American doctors,” he said. During those three or four years of residency, they also develop connections with their communities, which can entice them to stay.

Loan-forgiveness programs in the U.S. encourage doctors of any background to practice in rural areas, at least temporarily.

Minnesota has gone a step further to encourage foreign-trained doctors to go through the complex process to legally practice in the U.S. It’s the first state in the U.S. to implement a comprehensive program to integrate foreign-trained doctors into the workforce, according to the Minnesota Department of Health.

In 2015, the International Medical Graduates Assistance Program began addressing barriers for foreign-trained doctors trying to practice in Minnesota. A 2015 report found to practice in the U.S., foreign-trained physicians must complete an intensive process that takes on average three to five years - sometimes as many as 10 - and costs roughly $7,500 to $15,000.

There is fierce competition for residency spots for all doctors. Many programs limit applicants to those who have recently graduated, which may disqualify a more experienced doctor from another country.

Matthias said CentraCare scrutinizes the credentials of foreign-trained applicants just as it would any other candidate. The problem can sometimes be verifying that information on the other end, in the doctor’s home country.

“But we’ve gotten better at getting that,” he said.

Beyond obtaining a license, foreign-trained doctors can experience challenges that other doctors don’t contend with. While patients are getting more used to seeing a face that looks different than theirs in the doctor’s office, there are still some difficulties with acceptance.

Chaudhary found himself working 60- to 80-hour weeks after going to a practice in upstate New York in 2001. Of the four doctors in that practice at the time, Chaudhary was the only one of color.

“There were a few people who looked at me and said ’I don’t want to see you,’ ” he said. “I said, ’Fine.’ Eventually they realized there was nobody else and they would come back.”

He had just finished advanced training in cardiology, so after he finished his day in primary care he saw patients who needed a heart specialist.

“I got unbelievable experience,” Chaudhary said. “No matter how sick the patient was, I knew there was no backup. I have to take care of this. It gave me a lot of confidence. … I think it made me a stronger physician.”

At CentraCare, patients are becoming more used to seeing diverse faces, Matthias said.

“It’s a reflection of our time,” he said. “We reflect more of the diversity in our entire region.”

They hear fewer complaints than they used to. He compared it to reactions when women started entering the medical profession.

“Only a third of (my) medical school class was women,” he said. Now, women frequently outnumber men in medical schools.

One barrier physicians face, whether foreign-trained or from outside the Midwest, is dealing with Minnesota Nice.

“The biggest one is fitting into the community and to understand how we do things in Minnesota,” he said. “It’s different than the East Coast.”

Minnesotans can sometimes downplay pain or problems, because they don’t want to be a bother, or feel it’s rude to complain. Doctors have to recognize those signs and symptoms.

CentraCare pairs new physicians with more experienced ones, to help them assimilate to Minnesota. And they, in turn, help Minnesotans understand patients who don’t share similar backgrounds.

“They’re well-trained. They bring a diversity to an area of Central Minnesota that hasn’t been real diverse in the past,” Matthias said.

“They’re helping us better understand this broad melting pot of people (so we can) provide care to our patients. … Our patients are not all cut out of the same bolts of cloth,” he said.

Ultimately, it comes down to being a good doctor, Matthias said.

Hamdan, who has just finishing training in upstate New York, agreed.

“If you have a doctor that respects you and is taking care of you, there is no problem,” he said. “In part, this is how I was raised - to love people. Part of my religious culture is there is no difference between any human and another except based on piety. Since piety only God can read it, not you and me, I better … take care of you and leave the rest to God.”

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Information from: St. Cloud Times, https://www.sctimes.com