The Foreign Underclass in American Medicine

Every year, many graduates of foreign medical schools enter residency programs for specialized medical training in the United
States. Most of these doctors end up emigrating to this country. Over the years, these foreign medical graduates (FMGs) have
come to constitute a sizable chunk of the medical profession in America. According to the American Medical Association's
Physician Masterfile, in 1994 FMGs comprised nearly 24% of the 630,000-strong physician workforce in America. The largest
numbers of FMGs come from India and Pakistan, accounting for, respectively, about 20% and 12% of all FMGs in America.
Other prominent sources include the Philippines, Russia, Egypt, Israel, United Kingdom, Republic of Ireland and Germany.

In order to be eligible for American residencies, FMGs must pass the same qualifying examinations that are taken by American
medical students, in addition to demonstrating competence in English. It is implicit that once these hurdles are cleared, FMGs
can compete on the same footing with their American counterparts, but this is obviously not so. Although some FMGs are able
to make it to the most competitive training positions, the majority end up in what would be considered lower-tier residency
programs. Program directors follow an unwritten policy whereby FMGs are, for the most part, considered for only those
positions that American physicians aren't interested in. These are usually labor-intensive positions in inner-city hospitals and
were it not for FMGs, these residency slots would go unfilled. The ultimate basis for this, in my opinion, is straightforward: it is
the overpowering stigma of being foreign in America. Unlike in a Third World country such as Pakistan, where’foreign' evokes
positive images, in a world leader like America foreignness has a negative connotation. Thus the American medical
establishment considers FMGs to be inferior physicians compared to Americans, and this is reflected in FMGs being
overrepresented in the less popular residencies. This is extremely unfortunate and unjust. For not only do FMGs take the same
examination as American medical graduates, it has never been shown that FMGs are less competent than Americans.

Here's a little background. In the United States, fresh medical school graduates have to undergo a period of additional training,
which could be anything from 3 to 10 years depending on the specialty you choose, before they can be independent,
unsupervised medical practitioners. A highly structured system of graduate medical education has thus developed in America
to ensure the proper administration of this kind of training according to rigorous quality standards. The programs for graduate
medical training are generally referred to as residencies and fellowships. A residency is a program immediately following
medical school, representing the first level of specialization, such as medicine, surgery, radiology, pediatrics or psychiatry. A
fellowship is a program immediately following residency, representing the second level of specialization (or
sub-specialization), such as a fellowship in cardiology or rheumatology after a residency in medicine, or a fellowship in heart
surgery or plastic surgery after a residency in surgery. The origins of the residency system can be traced to the curriculum of
clinical teaching developed at Johns Hopkins by Osler, Halstead, Welch and Kelly in the early 1900s. It is a highly effective
system in which trainee doctors acquire firsthand clinical experience under supervision and are gradually given greater
independence and responsibility as they near the end of the program. This model quickly spread throughout the United States
and eventually, like most things American, became the envy of the world. A large number of doctors from other countries have
come to the United States to train in the residency system, attracted by the quality of professional training and the American
standard of living.

The influx of foreign doctors really began in the 1950s, when the postwar prosperity boom spawned many new hospitals and
created a huge demand for physician as well as non-physician medical personnel that could not be adequately met by
American medical schools. In his influential Pulitzer Prize-winning book’The Social Transformation of American Medicine', Paul
Starr describes the resulting phenomenon:

"During the 1950s, foreign medical graduates increased from 10 to 26 percent of all housestaff [in US hospitals]. Initially, these
doctors came primarily from Europe, but in the 1960s a major influx began from Asia, mainly Korea, India and the Philippines.
Though ostensibly in America for graduate training in hospitals, the majority chose to remain permanently. Like other
immigrants, they often took jobs that Americans did not want (for example, in state mental institutions). In effect, the peculiar
slant of American health policy (expanding hospitals, but keeping down medical [school] enrollments) was producing a new
lower tier in the medical profession drawn from the Third World."

FMGs were thus automatically relegated to a social and professional underclass within American medicine, and this was
based on their foreignness, without regard to competence. I think Starr's passage gives it away, especially in the second
sentence. Things were all right, he seems to say, so long as the foreigners were white and European, but the problem began
when they started coming from the Third World. Of course, this is not a novel sentiment in America and, in a sense, Starr is
just echoing this century's transition in the general American attitude towards immigration. After all, the United States was in
general happily and proudly a nation of immigrants so long as they were coming from Europe, but began despising immigrants
as soon as they became non-white. Indeed, the stigma of being foreign is so unequivocal that many foreign doctors now take
exception to being called an FMG and regard it as a term of derision, insisting instead on being called international medical
graduates or IMGs. (As a little aside, my personal view on this is that you can't run away from what you are: if you run away
from’FMG', soon’IMG' will acquire the same negative image. We'll just keeping chasing our tail, running away from being
foreign.)

For several years, almost up to the mid-seventies, the demand for residents remained so great that the system was able to
absorb almost anyone who wanted to come over. American prosperity seduced most of these people to stay, and immigration
procedures remained routine. But when the influx of FMGs began to threaten a physician oversupply in America, the
legislature stepped in. In 1976, the US Congress introduced a number of barriers to deter FMG immigration, of which perhaps
the best known is the 2-year home requirement of the J-1 Exchange Visitor Visa Program, which stipulates that a foreign
physician must, after completion of graduate training, return to his or her home country for a minimum of two years before
being eligible for any kind of US immigration.

Towards the late 1970s, enough doctors were being produced locally in America to fill up most of the available residencies,
and it became difficult for FMGs to find any spots. In the 1970s, many new medical schools had been founded and enrollment
in existing medical schools had been increased in order to meet the demand of the residency system. By the early 1980s,
therefore, the residency boom for foreign doctors was clearly over. Interestingly, however, it did not stay that way for long.
Around the mid-1980s, the numbers of available residencies were further increased. The main impetus for this was monetary,
aiming to exploit the generous Medicare subsidy of graduate medical education. Because Medicare has large sums of money
earmarked for residency training (only a fraction of which goes towards residents' salaries), hospitals soon realized that
residency programs were actually lucrative ventures. Thus, although not to as great an extent as in the 1960s, the number of
available residencies once again began to exceed the output of American medical schools beginning around 1987, so that by
the early 1990s, the residency boom for FMGs was back with full force. While the barriers to doctors' immigration have
remained in the rulebooks during this second boom, many opportunities for circumventing these hurdles have become
available and the proportion of FMGs who manage to emigrate remains extremely high. For example, it has become
commonplace for FMGs to get green cards after finishing residencies by taking up jobs in so-called’underserved' areas that
American doctors don't want.

As we approach the end of the decade, the second residency boom is also grinding to an end. One reason is that in the
post-cold war world there are suddenly many more FMGs free to compete for entry into American training. Perhaps more
importantly, however, the number of available positions are also being scaled back. This is especially true in New York, which
has always had a large FMG population, but where the state is now actually rewarding hospitals with money if they don't take
foreign residents.

The academic and professional climate has thus become hostile to FMGs. It is hard to project if and when this might change.
The traditional complaint lodged by detractors of FMGs is that foreign doctors don't go back home. This defeats the purpose of
training FMGs which, they argue, should be to take world-class medical expertise back to the developing world. This strikes
me as a very unfair portrayal. For one, the original purpose of accepting foreign residents was to satisfy manpower shortage,
not to be a center for Third World medical reform, and it is rather disingenuous to suggest otherwise; for another, who can
blame FMGs for not wanting to go back to the misery and destitution of the Third World ? After all, why would FMGs be any
different from the huge mass of people from Africa and Asia desperate to make a home in America if given the chance ?
Finally, the expectation that repatriating FMGs will somehow effect a national change in the health of a developing country is
in itself laughable. National health is a highly complex problem deeply interconnected with the social, political and economic
fabric of a country; expecting the problem to go away by throwing American-trained tertiary-care specialists at it is simply
illiterate.

I believe the main reason the American medical order is bothered by foreign medical graduates is that they have exploited a
route of entry into America that not only by-passes the standard immigration line, it also acts as a short-circuit into a
prestigious social class. The establishment's displeasure is hard to miss. Over the last few years, a number of articles have
appeared in leading professional journals decrying the FMG problem (for example, Iglehart's ’The Quandary over Graduates of
Foreign Medical Schools in the United States', in the New England Journal of Medicine, 334:1679; and Mullan et al's ’Medical
Migration and the Physician Workforce: international medical graduates and American medicine', in the Journal of the
American Medical Association, 273:1521). It is the same message being echoed from different sources, namely, that FMGs are
compounding a physician oversupply and opportunities for them to train and practice in the United States should be curtailed.

The Clinton Administration has expressed its intent to reduce the number of medical residencies to 110% of graduating
American medical seniors. Because of this, and because American college graduates are applying in record numbers to
medical school, the FMG honeymoon in America is probably finally over. As you may have gathered, this bothers me,
although I am not sure if my grievance is entirely legitimate. Thinking rationally, I think one has to conclude that it is ultimately
America's prerogative: it's their country and they can do with it what they want. If they don't want any FMGs, that's really up to
them, isn't it. If anything, this will force us to give structure to medical specialization in our own country. I must confess,
however, that having trained here as an FMG myself there is nevertheless also a part of me that wants to fiercely protect the
ability of the global community to access the American model of graduate medical education. After all, since the training
system begun by Osler and Halstead remains unequaled in the world, one could argue that it is an obligation on America's
part to continue sharing it with the rest of us. Besides, isn't it a kind of protectionism to limit training opportunities for foreign
doctors ?

In any case, even leaving the FMG factor out of the equation, the changing complexion of American medicine cannot be
avoided. Asian-American and desi-American graduates of leading American medical schools are beginning to dominate the
profession. If preserving whiteness was the main concern, then it is already too late!