February 7, 1974
Page 2658
OUR DEPENDENCE ON FOREIGN-TRAINED PHYSICIANS: IS IT FAIR?
Mr. MUSKIE. Mr. President, one of our most pressing health needs is adequate health manpower – adequate not only in numbers to meet our health needs, but also distributed throughout our central cities and rural areas in such a way that our medically "under-serviced" can get good health care.
One important resource for America in meeting both of those goals has been the foreign-trained physician. Today, there are almost 60,000 foreign-trained physicians in the country, estimated to make up about 20 percent of doctors in America. The foreign-trained physician has made an important contribution to American health care in all areas.
But our reliance on foreign-trained physicians raises a number of important questions. We must ask why we do not have sufficient health manpower training resources in our country to meet our own health needs. And second, we must ask whether it is fair for the United States to attract from foreign countries, by virtue of our high level of compensation and support for physicians, doctors who might be even more needed elsewhere in the world.
These questions were discussed more thoroughly in an article last April in the American Journal of Psychiatry, by Dr. E. Fuller Torrey and Dr. Robert L. Taylor. I ask unanimous consent that this article, together with more recent articles on the same subject from the Washington Star-News and the Washington Post be printed in the RECORD.
There being no objection, the articles were ordered to be printed in the RECORD, as follows:
CHEAP LABOR FROM POOR NATIONS
(By E. Fuller Torrey, M.D., and Robert L. Taylor, M.D.)
A recent issue of Psychiatric News, the official newspaper of the American Psychiatric Association, contained a remarkable letter. It was from a psychiatrist who advocated increasing the loopholes for using non-licensed foreign doctors in state mental hospitals. The rationale given was that the only American psychiatrists he had been able to recruit had turned out to be alcoholics, drug addicts, or otherwise seriously disturbed and therefore that foreign doctors were certainly to be preferred.
This letter affords a capsule summary of a serious problem facing American medicine in general and American psychiatry in particular. It is the problem of having to import large numbers of foreign doctors to staff our hospitals for the mentally ill. There are indications that these doctors are used primarily to staff public institutions, that some of them may not provide as high a level of care as their American-trained counterparts, and that they are badly needed in the countries of their origin. This paper discusses the problem and offers some solutions.
While there are no absolute figures on the number of foreign medical graduates being used in American psychiatry, there are some indicators. In American medicine generally it is known that approximately 8,500 foreign medical graduates enter the United States each year; since 1967 the number entering annually has been greater than the total number of doctors graduating from U.S. medical schools. It is also known that in 1970 there were 3,016 foreign medical graduates who were given licenses to practice permanently in the United States; these constituted 33 percent of all newly licensed physicians. In 1971 foreign medical graduates comprised over half of all new licensees in 13 states, and in two (Maine and Delaware) they were more than 90 percent of all new licensees.
Specifically in regard to psychiatrists, it is known that during 1970, 34 percent of all psychiatric residents (1,370 out of 4,040) were foreign medical graduates. Of the 186 residency programs that were active, 28 were completely filled by foreigners. In fact, there were more psychiatric residents in American hospitals who had graduated from the medical schools of the University of Havana (77) or from the University of Santo Tomes in Manila (74) than there were graduates of any American or Canadian medical school.
One of the largest groups of foreign-trained doctors in American psychiatry rarely shows up on official statistics. These are the unlicensed doctors who practice in state hospitals using temporary permits issued by a state and valid only for state institutions. All but seven states have loopholes in their licensing laws that allow such temporary licensing. The permits are renewable yearly for an unlimited number of years. In New York and Ohio, 40 percent of the physicians in the state mental hospitals are unlicensed. In West Virginia it is over 90 percent. If 40 percent is a representative average for the United States, there would be approximately 3,100 unlicensed foreign doctors staffing state mental facilities in this country. One AMA spokesman estimated that the number is more like 7,500.
FOREIGN PSYCHIATRISTS AS "CHEAP LABOR"
Foreign-trained psychiatrists work predominantly in those institutions which American psychiatrists consider the least desirable. Thus they are found in large numbers in city and state hospitals, prison hospitals, and institutions for the mentally retarded. Elmhurst City Hospital in New York City had 35 psychiatric residents in 1970, all of whom were foreign trained. State mental hospital residency programs depend very heavily upon them, as table 1 shows. Less than five percent of foreign-trained psychiatrists are in private practice in this country, in contrast to the more than 50 percent of U.S. trained psychiatrists who are.
Theoretically foreign medical graduates are in residency training programs for training. But in fact such programs are often so burdened by the service needs of the state institutions that little time remains for any formal training. If the foreign graduate is unlicensed, he may be confined to the state system that has granted him his temporary permit until he can pass the state licensing examination. Some states also use psychiatric residency slots as administrative mechanisms for hiring foreign doctors at a lower salary than a full staff position would require, or when no full staff positions are available. This may help to explain why in 1971 at least five foreign-trained psychiatric residents were over the age of 60; two of these were 69. Such residents can presumably receive both a stipend for training and Social Security retirement benefits simultaneously.
Because of their concentration in public institutions, patients who cannot afford private psychiatric care are more likely to be treated by foreign-trained psychiatrists. Table 2 indicates this pattern. The cost of hospitalization in an institution like the Columbia Psychiatric Institute in New York or Timberlawn Hospital in Dallas may be as high as $3,000 a month; the state hospital is of course free if the patient has no money. This is consistent with other aspects of American psychiatry and can be summarized by Arnold Rogow's observation: "Perhaps the only firm conclusion is that Americans, in general, receive the psychiatrist and the psychiatric treatment not that they deserve, but that they can pay for ..."
THE QUALITY OF CARE
The majority of great ideas and advances in psychiatry have come from foreign-trained psychiatrists. Kraepelin, Freud, Jung, Adler, and many others not only were trained in foreign institutions but made their major contributions in foreign countries. Thus there is nothing inherently inferior (or superior) in being foreign-trained; rather, it depends solely upon the individual psychiatrist and his specific training experience.
It is likely that many leaders of American psychiatry will emerge from among the large influx of foreign psychiatrists coming to the United States. However, there are also indications that among the foreign-trained group there are some whose level of psychiatric expertise is not up to generally accepted American standards. This is seen most readily among a few of the unlicensed doctors, such as the doctor in a New York State mental hospital who was successfully sued for neglecting a fatal subdural hemorrhage or the alleged doctor in an Illinois mental hospital who was recently charged with reckless conduct for the treatment of three patients who died.
The majority of foreign medical schools offer little or no psychiatric teaching to medical students. When they graduate, these doctors often arrive in the U.S. for a psychiatric residency with less knowledge of psychiatry than most American trainees at the same level. If the residency is in a hospital with a heavy service commitment, such as a state, hospital, the resident will find it even more difficult to catch up.
Language difficulties compound the problem. Psychiatry, in contrast to radiology or pathology, is the medical specialty in which communication between the doctor and the patient is absolutely essential for adequate diagnosis and treatment. Equally important are possible cultural differences and the lack of a similar world view between doctor and patient. Imagine the difficulty, for instance, of a psychiatric resident from Korea trying to assess the mental problems of a drug-abusing American adolescent who is undergoing an existential crisis. In the light of such communication barriers a statement made by the director of mental hygiene in Ohio is slightly odd. In announcing special basic English courses for doctors in the state mental institutions he said: "I hasten to point out that we seldom hear a complaint that our foreign doctors are not providing adequate care and psychiatric treatment for their patients. The complaints center only around the inability to communicate."
There are objective indicators that American psychiatry may not be attracting the best of the foreign medical graduates. One such indicator is the examination of the Education Council for Foreign Medical Graduates (ECFMG), an examination offered to medical graduates all over the world as a measure of their medical knowledge. It is made up in such a way that 98 percent of American medical graduates taking it for credit pass it. When it is given to medical graduates all over the world, only 40 percent of them pass it. Looking specifically at the pass rate for the eight foreign medical schools that contributed the greatest number of residents to American psychiatry in 1970, only two attained the worldwide average of 40 percent or higher. The two medical schools contributing the most psychiatric residents (the University of Havana and the University of Santo Tomas) had pass rates of only 20 and 13 percent, respectively. Similarly, on state licensure examinations the graduates of these two schools scored below the average pass rate of 63 percent for all foreign medical graduates. This in turn is considerably below the pass rate of 91 percent for American medical graduates. Four foreign medical graduates actually failed state board examinations for the 13th time during 1970. Between failures, such individuals may remain employed in state hospitals in most states on temporary permits.
In order to fully assess the quality of care offered by psychiatrists who have been trained abroad, a careful clinical examination would have to be given. At present, this has not been done. In fact, it is quite conceivable for a foreign medical graduate to come to the United States and become fully licensed to practice psychiatry without ever being tested on his psychiatric knowledge. The examinations that he must pass (the ECFMG and a state board) have very few questions on psychiatry, and his residence program may never examine him formally.
THE "BRAIN DRAIN"
The other major consequence of using large numbers of foreign psychiatrists as cheap labor for the United States is the effect this has on the countries from which the foreign doctors come. This has been referred to as the "brain drain."
The countries that contributed the greatest number of psychiatric residents to the United States in 1970 were the following: the Philippines – 149 residents, India – 136, Korea – 107, Cuba – 95, Argentina – 55, Colombia – 46, Iran – 39, Mexico – 25, Egypt – 19, and Pakistan – 19. This list corresponds with the frequently cited estimate that 85 percent of our imported medical manpower comes from underdeveloped countries.
While it is often said that the Philippines produces more doctors than it needs, this is not true. Only Manila and the other large cities are oversupplied with physicians; the remainder of the country has a low doctor-population ratio. Yet Filipino doctors are continuing to come to the United States in large numbers. The number of medical graduates taking the ECFMG in Manila is now so large that a football stadium has to be used to accommodate them for the examination.
Korea is another country that has been hit especially hard by the flow of trained doctors to the United States. In the past 20 years 23 percent of its physicians have departed, and only 3 percent have returned. Recently 90 percent of the graduates of one Korean medical school left Korea for U.S. internships; this same year there were 65 vacant internships in Korea. Korea, it should be noted, has a doctor-population ratio outside the capital of 1 to 17,000; the United States has a ratio of 1 to 700.
Overall it is not known how many of the foreign medical graduates who come to the United States for psychiatric training return to their homelands, but it is agreed that the returnees are a minority. A study of psychiatric residents from Mexico in the United States showed that 46 percent of them eventually returned to Mexico. A director of a training program staffed predominantly with foreign residents found the return rate to be much lower: only two of his 34 foreign psychiatric residents from developing countries had ever returned to their homelands to practice. Furthermore, even for those who do return, it may be questioned whether the quality of their training experience has been appropriate for their country's needs on their return home.
It is known that taking this medical manpower from other lands saves the United States a large amount of money. If the 3,016 foreign doctors who were permanently licensed in the United States in 1970 had to be trained in the United States, they would require the addition of 30 new medical schools. To build a medical school costs at least $50 million and to operate one for a year averages $3.8 million. Thus the total amount needed to replace the foreign-trained doctors who were permanently licensed last year would be $1.6 billion. This is the equivalent of over half of the total U.S. foreign aid program. When this amount is added to other aspects of the brain drain, it may well be that our foreign aid program is in effect canceled altogether.
HOW THE PROBLEM CAME ABOUT
It is useful to inquire in retrospect how it developed that the United States is finding it necessary to import large numbers of psychiatrists from poor nations to staff our public mental institutions.
Understanding the roots of the problem may be an initial step toward correcting it.
First it should be noted that a conscious conspiracy to take doctors from poor countries does not exist. Conspiracies imply planning, and anyone familiar with the inner workings of American psychiatry knows that this degree of planning simply does not exist. It is, in fact, the absence of planning that is closer to the root of the problem.
Who, then, is responsible for the absence of planning? Certainly not the foreign doctors themselves, who are only availing themselves of the best opportunities to further their careers and their livelihood. Indeed how many American psychiatrists can say that they would not move to Manila to practice if they were offered a salary ten times what they are making here? Nor can public mental hospital administrators be held responsible, they are just trying to carry out their mandate to secure psychiatrists for their staffs.
Planning for the needs of American psychiatric manpower theoretically rests with the federal government (through the National Institute of Mental Health and the Bureau of Health Manpower Education) and with the professional associations (the American Medical Association and the American Psychiatric Association). We believe that none of these organizations has done a satisfactory job of planning; this is the root of the problem.
The National Institute of Mental Health has supported the training of psychiatrists since World War II, until recently at a rate of $40 million a year. Yet during this time it has made virtually no effort to ascertain what the psychiatrist was doing once he was trained. If it had gathered such data, it might have instituted a period of mandatory public service for psychiatrists who had been trained with public money. This would have ensured some psychiatric manpower for public institutions rather than allowing the psychiatrists to go immediately into private practice.
Similarly, the Bureau of Health Manpower Education has concentrated too much attention on increasing the total number of doctors and too little on the geographical distribution of the doctors. The myth has been that if the total number is increased sufficiently, there will be enough to go around. This is apparently not true. In the Philippines, for instance, there is an excess of doctors in the capital city, but the excess doctors have been found driving taxis and taking other jobs rather than leaving the capital to practice medicine in rural areas, where they are badly needed. It may well be that the United States already has enough doctors (and particularly psychiatrists) for its overall needs, if they were distributed more evenly. Our 25,000 psychiatrists constitute almost one-third of the world's total. Certainly many European countries are providing superior public psychiatric services with a far lower psychiatrist-population ratio than we have.
The American Medical Association has been doubly shortsighted. For many years this organization denied the existence of an impending doctor shortage. More recently it has acknowledged that there is a shortage, but has reacted only by trying to increase the absolute numbers without attempting to affect the geographical or specialty distribution. The American Psychiatric Association has made these same errors and has assumed that increasing the number of psychiatrists would somehow improve public service.
Both of these professional organizations may also be faulted for rigidly upholding outmoded standards that require a person with a medical license (i.e.., a psychiatrist or other physician) for many jobs in public mental institutions that could just as satisfactorily be done by a person without a medical license (i.e.., a psychologist, social worker, or nurse). Similarly, it is the combination of these two organizations that has accredited the state hospital residency "training" programs, which are training in name only and really are means of obtaining service personnel.
The U.S. Immigration Service and the State Department have compounded the problem of foreign doctors coming to this country. The liberalized immigration laws enacted in 1962, 1965, and 1970 made it increasingly easy for doctors to both come to and remain in this country. These liberalizations in the laws were made despite hearings warning against them in the Senate in 1967 (before the Senate Subcommittee on Immigration) and in the House of Representatives in 1968 (before the House Committee on Government Operations). Even prior to that (in 1966) Senator Walter Mondale raised his voice on the Senate floor and called the brain drain "a national disgrace." Simultaneously the State Department was compiling a report attempting to deny that any brain drain problem existed.
The problem is also due to lack of planning in the developing countries themselves. By not setting up training facilities in their own hospitals, by often retaining a promotion system based on seniority rather than ability, and by permitting their doctors to leave before they have repaid their public-subsidized medical training with public service, the developing countries have encouraged their doctors to permanently emigrate to the United States and other countries.
SOME SUGGESTED SOLUTIONS
The problem of having to import large numbers of doctors from poor nations to staff our public mental institutions is a very serious one; it demands a solution. The following are suggested directions that could be pursued:
1. Functional job analysis. Psychiatry is going to have to do some hard thinking and functional job analysis on the tasks that psychiatrist are currently doing. Exactly what kind of training does one actually need to treat persons who are mentally ill? Do we really believe that an Iranian or a Korean psychiatrist, because he is a psychiatrist, is more effective than an American clinical psychologist in treating an American patient who is mentally ill?
2. Public service. American psychiatrists who are trained with public money should be expected to repay their debt with a period of public service and not just go directly into private practice. A loan system to replace present stipends would be one way to bring this about.
3. Accreditation. A system of mandatory accreditation is needed for every psychiatrist and psychiatric training program. This would help screen competent psychiatrists from those who are not competent.
4. Separation of training and service. In order to make all psychiatric residency training programs into true training programs, they must not be based on service needs. The service needs of public mental institutions must be filled apart from any training programs taking place there. Until this is done it is inevitable that some training programs will be merely facades for delivering services through the use of less expensive personnel. And if the trainees themselves are allowed to define how they want to achieve their training goals, one has the beginning of a true system of education.
5. Improved training abroad. It is possible to improve the training of doctors in their home countries so as to obviate the necessity for many of them to come to the United States on what become one-way trips. For instance, television and communications satellites will soon be available for long-distance teaching. Another possible use of modern technology would be to hook up computer outlets in other countries to an information and retrieval system in the National Library of Medicine.
6. Specialized training programs. There should be specialized training programs in which psychiatrists from abroad would come here to learn specialized skills and then return to their own countries. These programs would emphasize aspects of psychiatry that are appropriate for the developing countries. An excellent example of what can be done along these lines is the program for Indonesian psychiatrists set up at the University of Hawaii under Dr. John McDermott.
7. Changes in the immigration laws. Finally there would have to be changes in the immigration laws so as to make it more difficult for foreign doctors to stay in the United States.
We recognize that solutions which include such things as obligated public service in exchange for public training and mandatory accreditation for individual psychiatrists are in conflict with the inclinations of many American psychiatrists. These are, it is said, contrary to the free enterprise model. We do not think that this is necessarily so. Benjamin Rush was both the father of American psychiatry and a signer of the Declaration of Independence. It is doubtful whether he saw a free enterprise system as meaning the freedom to take manpower from poorer countries in order to provide public services in wealthier ones.
We also recognize that these solutions are not simple. But then, neither is the problem. American medicine in general, and American psychiatry in particular, are currently so dependent on foreign doctors that to suddenly remove them would precipitate a collapse of the whole system.
Solutions must be found. We should move rapidly toward a point when no longer would one find vignettes like one recently published in The Washington Post on conditions at the state prison in West Virginia. The article described the need for professional help for the inmates and mentioned that there is one psychiatrist "but he is a Cuban and does not speak English." American psychiatry should be able to do better than this.
[Footnotes omitted]
DISCUSSION
(By Robert Cserr, M.D.)
MEDFIELD, Mass.– To begin with a very unambiguous statement regarding this paper, the authors have portrayed the problem of foreign-trained physicians very accurately. They are telling it as it currently is, although I wonder at their figure of 50 percent of American psychiatrists being engaged in full time private practice. The impressions that foreign-trained psychiatrists work in settings (usually institutional) that U.S. psychiatrists consider the least desirable and that "training" for them is often really a euphemism for "service work" because of the absence of real supervisory concern for their assimilation of knowledge are unfortunately very accurate in many instances.
Certainly, as the authors point out, there is no reason to feel that the quality of care per se delivered by a foreign-trained psychiatrist need be inferior to that delivered by his U.S.-trained counterpart. But with the two-class system of psychiatric training supported in this country, this frequently represents reality. What seems to prevail for foreign physicians, therefore, is: 1) their use (or misuse, as the case may be) as primary service-deliverers, although they are said to be in training, and 2) their general inadequacy, because of the lack of special attention to their needs, for the American psychiatric scene.
I would like to discuss these two issues and the specific approaches we have undertaken at Medfield State Hospital to deal with them; some of our work seems very much in consonance with the spirit of this article. First, to insist that only physicians are capable and effective in the areas of evaluation and treatment is unmitigated foolishness. At Medfield we have been able to remove all residents in training from the area of primary delivery of services by creating a cadre of clinical case administrators (paramedical professionals and pre-professionals), through whom the service needs of the patients are met. Supervision of these case administrators is by a group of experienced professionals, including psychiatrists. Residents have a bona fide training program: the service they give, although frequently extensive and valuable, is incidental to and a part of their training. This approach has indicated to us quite unequivocally the direction in which we must move to increase the extent and quality of services – namely, the training and employment of these other professionals and pre-professionals.
Second, special attention must be paid to the background and needs of the physicians-in-training from developing nations. There must be a flexible curriculum that includes subjects relevant to their needs, so that they can function as psychiatrists both in the U.S. setting and in their own nations after their training is completed.
The New England Psychiatric Society recently surveyed the problems concerning foreign-trained psychiatrists in our area. Dr. N. S. Mittell, Medfield's director of residency training, headed a task force that developed a recommendation to create an ombudsman to help foreign medical graduates get through the developmental crisis that confront them in adapting to American society and psychiatry. The ombudsman would also attempt to ameliorate the numerous irrational harassments facing these physicians.
I would now like to comment on the author's proposed solutions of the problems concerning foreign medical graduates; I agree with some but disagree philosophically with others.
Certainly far too much public money has been spent on training psychiatrists who immediately move into the private sector with little recognition of their obligation to the public sector for subsidizing their training. But the attraction, both in terms of financial reward and in the opportunity to work with relatively more gratifying and less troublesome patients, is an overwhelming inducement. However, this is only one factor. I shall discuss another – the negative attitude prevailing in many state hospitals – shortly.
Surely some arrangements can be made incorporating the concept of universal conscription for a limited period of time for those trained at the public expense; this could even include the military as a "public institution" in which professionals could meet their obligations. However, I would strongly disagree with any plan that would definitively and perhaps permanently deprive any person, including a physician, of the freedom to practice his profession or trade where he wants.
Such a policy would ultimately have devastating effects on the quality of the trade or profession. Although the authors do not say so explicitly, I am left with the uncomfortable feeling that, in their frustration, the authors are suggesting that, in order to ameliorate the situation in which foreign physicians are impressed into "slave service" labor in public hospitals, U.S. psychiatrists should be treated in the same repressive way then all would be equitable. This would hardly be a solution; in fact, I would expect this approach to compound the already indefensible situation present in so many of our public institutions. I would like to recall the approach I mentioned earlier: the greater use of other professionals and pre-professionals, which seems very much in accord with the authors' ideas.
In addition, I want to stress a very important issue that the authors seem to have neglected – namely, the conditions in and attitudes of many public institutions, which allow and indeed encourage poor care and care givers. Certainly the feudal attitudes on the part of the administrators of many public institutions hardly provide an incentive to anyone to find newer and better ways of rendering service. A dismal attitude on the part of professionals in public service, and in the private sector as well, has been shared for a long time by the community, which makes the job of change far more difficult but at the same time far more challenging and potentially rewarding. No amount of "quota-ing," in-country or out-of-country, is going to solve what is essentially a philosophical and attitudinal problem; only the people in charge of the institutions can begin to do that. Public institutions, including state hospitals, must change their philosophies and attitudes drastically so that an air of rejuvenation rises from the old edifice, so that it becomes an exciting place to be rather than a warehouse, so that its considerable resources are deployed in active treatment, not as a home for the persona non grata. In the process of this transformation, improved training, both abroad and in this country, perhaps subsidized by both governments, can be developed. The obligations to their own country and to the United States that must be met by the resident-in-training can be specified. Rather than using the U.S. society as a prototype, the specific needs of developing nations might be considered in the training that foreign psychiatrists receive, both in the United States and in their own countries.
But the development of all this will have to be based on a change in attitude, not on military discipline. Many of the problems relating to foreign-trained physicians in second-class settings, where they are employed as "cheap labor" while ostensibly in training, would cease to exist if the second-class settings themselves moved with conviction toward becoming first-class. In addition to the resources currently available to them, they would need a great deal of imagination and daring and much more hard work. This is the approach we are using at Medfield State Hospital; it seems to be working.
It would be well for me to point out in conclusion that there are many paths for a career in psychiatry; that public and private service can and ought to coexist and that working with severely deprived or ego-damaged individuals is quite different from working with gifted individuals to further develop their considerable potential. (The two poles seem, at times, to be equated with public service and private practice, respectively.) Certainly both of these tasks are important; I will not debate which is more valuable to our society as a whole, although the latter will continue for a time to be compensated better, both financially and in terms of prestige, until some effective counter-compensations emerge. These counter-compensations are what I alluded to when I talked about change as a foundation for a public institution program. Psychiatry must become aware of the reality of the position it is finding itself in today with regard to the demands for and expectations of service. It must not move to either extreme – to the public sector at the expense of the private or to the private sector at the expense of the public. Either extreme, as with human beings and their behavior, brings forth trouble, which we call pathology. Certainly psychiatry should be able to reconcile the disparate elements of its feelings and behavior better than that, and further both public and private programs without resorting to extremism.
HEW STUDY SAYS 20 PERCENT OF U.S. DOCTORS ARE FOREIGN TRAINED
(By Stuart Auerbach)
One out of every five doctors in America graduated from a foreign medical school where he most likely received a substandard education, according to a study commissioned by the federal government.
Moreover, the study shows that the immigration of doctors to America is foreign aid in reverse and often hurts other nations who consider doctors a valuable resource.
The number of foreign medical graduates here has doubled in the past 10 years, and most of the foreign-trained doctors work in American hospitals, where they make up one third of the medical staff.
"Available evidence indicates that foreign manpower has been imported to serve specific roles, particularly in hospitals, rather than to fill a general manpower need," the report states.
"The fact that many foreign physicians have stayed in the United States is largely a secondary result of this primary activity. Nevertheless, the cold facts remains that 63,391 of the 334,028 physicians in the United States in 1970 received their primary medical education outside the United States.
"This education represents a huge net gain to this country in terms of value received for medical education."
The study, commissioned by the Department of Health, Education and Welfare, was finished one year ago by Rosemary Stevens and Joan Vermeulen of the Yale University Medical School. It was, however, just released this month by HEW.
HEW sources say the report was held up because of possible embarrassment to the government and was released after congressional inquiries as to its status.
It shows that more foreign trained doctors (10,540) entered the United States in 1971 than graduated that year from American medical schools (8,974).
While 25,000 of the foreign-trained doctors were educated in Europe, 21,000 of them came from underdeveloped countries in Asia, principally the Philippines, India and Korea.
"There are more Thai graduates in New York than there are serving Thailand's rural population of 28 million," the report says.
"Iran produces 600 medical graduates a year;on the average there are at least 100 (members) of the graduating classes from 1960 through 1969 now in the United States. Many, if not most, will stay; In 1970 alone, 806 Iranian medical graduates sat for American licensing examinations.
Similar statements can be made for many, if not most, third-world nations." Despite the loss to other nations, there are signs that the American government considers the migration of foreign- trained doctors a plus for this country.
For example, HEW Secretary Caspar W. Weinberger told the House health subcommittee this year that there is no need to spend more federal funds on American medical schools to increase the number of doctors they graduate since so many foreign-trained doctors are coming to this country.
But the HEW-commissioned study conclues that foreign medical graduates are not as well trained as American-trained physicians.
"Indications are," the study says, "that foreign medical graduates continue to perform less well than their American counterparts even after several years of American graduate training."
For instance, 37 per cent of the graduates of foreign medical schools failed to pass their tests for American licenses, compared to 9 per cent of the graduates of American medical schools.
The same is true for the performance of foreign-trained doctors on specialty board examinations.
Many foreign-trained doctors working in hospitals do not need licenses. If they are residents or interns, they are considered doctors in training, and if they are full time employees of the hospital they may be considered to be working under the supervision of a licensed physician.
If it were not for foreign-trained doctors, many hospitals would not be able to fill their slots of interns and residents who, although they are supposed to be receiving training, often provide the bulk of patient care.
American hospitals offer more than 15,000 internships to recent medical school graduates; only 8,213 – about half – are filled by graduates of American medical schools.
As a rule, the American medical graduates go to the best hospitals where they will get best training, leaving the rest for the foreign graduates. Many foreign-trained doctors are hired by city and state hospitals because American-trained physicians will not work for the low wages paid there.
FOREIGN MEDICAL GRADUATES
(By Judith Randal)
Which of the following statements is correct?
Of the some 63,000 physicians practicing in this country who were not trained in either the United States or Canada – usually referred to as Foreign Medical Graduates or FMGs – the most recent arrivals are:
(1) More numerous than their predecessors of 10-15 years ago.
(2) More likely to be natives of underdeveloped nations whose need for doctors is even greater than our own.
(3) Also more likely to be second-class citizens professionally.
All these statements are correct and their implications both domestically and internationally are disturbing. It is bad enough to have this happen at a time when only an estimated 34 percent of those who apply to U.S. medical schools have a chance of getting in (down from the approximately 50 percent that it was until recently). Even worse, it threatens to intensify what already is a serious drawback of the nation's health care system: uneven quality.
When most doctor immigrants were European graduates of top-notch schools they frequently were of an age or professional stature to become professors or researchers or to join the staffs of major teaching hospitals for the best and most sophisticated training. Now, however, the typical new M.D. arrival is likely not only to be younger and to have come from India, the Philippines, South Korea, Pakistan or Thailand, but also to be recruited for positions which, because of the shortage of American graduates, would otherwise go begging.
Specifically, about half of all the doctors now being licensed in this country are FMGs, and in some eastern states, particularly, the percentage is far higher. They are to be found in disproportionate numbers in state mental institutions and in hospitals in inner city and rural areas that are isolated from the mainstream of what is best in medicine, as well as in hospital emergency rooms and among those specialties such as anesthesiology and pathology which are the least attractive to Americans.
"Foreign Trained Physicians and American Medicine," a Department of Health, Education and Welfare publication from which most of this data is taken, points out (and correctly) that their backgrounds are so varied that neither a wholesale indictment nor a wholesale endorsement of FMGs is possible.
Yet it also is true that many state licensure boards have had to lower their passing grades in order to permit a sufficient number of FMGs to qualify; that numerous state mental institutions are largely staffed by FMGs for whom licensure has been waived or modified, and that – because remedial opportunities are limited – relatively few of these men and women ever make up for whatever professional shortcomings they may bring with them from abroad.
Small wonder, then, that since FMGs are disadvantaged, many of their patients in one way or another are, too. It is hardly accidental that the people whose health care is least likely to be provided by American medical graduates do not belong to metropolitan upper-income groups.
Many people would argue that any doctor is better than no doctor at all. Another way to look at it, however, is that much of what physicians do can be done as well or better by well-supervised technicians and that to continue to drain other countries of their doctors instead of reorganizing the system to take advantage of this is wasteful and costly.
Furthermore, the United States trains far more of certain kinds of doctors – notably surgeons – than the population warrants, one result being that unnecessary operations help to create the seeming shortage of some of the very categories of supporting specialists – such as anesthesiologists – that we now import.
Thus, even if we continue to deny the entry of many qualified applicants to medical school, it should be possible to get a handle on overproduction in some specialties and underproduction in others, either by government intervention of some sort or by tightening health-insurance payment mechanisms for patient care which now indirectly subsidize most doctors who go on for further training after earning an M.D. degree.
A final note: The money the governments of under-developed nations have spent and are spending to train doctors who then leave for the U.S. amounts to billions of dollars' worth of foreign aid in reverse. Unintentionally given by those who can least afford it, it is resented even more intensely than assistance provided by the "haves" to the "have nots."