Correspondence

Graduates of Foreign Medical Schools in the United States

N Engl J Med 1996; 335:1535-1537November 14, 1996

Article

To the Editor:

Iglehart's discussion of the quandary over graduates of foreign medical schools in the United States (June 20 issue)1 highlights several issues. We train residents to provide the country with the work force needed for the next 30 years and to provide trainees with current knowledge and the tools to advance that knowledge. The United States, with its advanced medical-education system, has a responsibility to train the brightest young physicians from less developed countries, who should take that training back to their own countries. It is appropriate for the federal government to fund both these elements of graduate medical education directly.

As Iglehart points out, over the years a number of unrelated items have been grafted onto funding for graduate medical education, including the provision of low-cost medical care for indigent patients and underserved regions and the subsidization of medical schools and hospitals, particularly those with large numbers of indigent patients. The fear is that reducing the number of residency-training positions would severely compromise the care of indigent patients and destroy academic medical centers and medical school departments.

Some have suggested that marketplace economics will eventually correct the situation. They cite the example of anesthesiology, pointing out that a reduction in the amount of surgery being performed and the training of nurse anesthetists have turned a highly sought-after residency into one for which less than half the training positions offered last year were filled. Unfortunately, marketplace economics takes no account of indigent patients or the needs of inner-city hospitals or rural areas.

The resolution of the current problems will come not from restricting the training of graduates of foreign medical schools but, rather, from separating the financial support of academic medical centers and departments from society's responsibility for the care of indigent patients. The use of low-salaried residents to provide care for indigent patients inappropriately underfunds that element of our health care system. Society should recognize the true cost of such care, and money should be shifted from supplements for graduate medical education to direct support of the institutions providing care for indigent patients. There will be a substantial reduction in the number of residency-training positions, but this does not necessitate the wholesale closure of academic medical centers and medical school departments.

Walter G. Bradley, D.M.
University of Miami School of Medicine, Miami, FL 33101

1 References

1. 1

   Iglehart JK. The quandary over graduates of foreign medical schools in the United States. N Engl J Med 1996;334:1679-1683
   Full Text | Web of Science | Medline

To the Editor:

Of the graduates of foreign medical schools currently enrolled in graduate medical-education programs in the United States, approximately 50 percent are citizens or immigrants who have made the United States their adopted and permanent home. Equal employment opportunities and civil rights apply to us as well as anybody else in this country.

All recommendations for reform of policies governing the medical work force in the United States should adhere to the principle that individual qualifications, skills, and character — not citizenship or country of medical school graduation — are the sole criteria for the purposes of entry into graduate medical-education programs, licensure, and selection of providers for managed-care plans.

Bernd Wollschlaeger, M.D.
University of Miami School of Medicine, Miami Beach, FL 33139-5597

To the Editor:

U.S. medical education and practice, like many other aspects of American life, are highly polarized. At one end of the spectrum are prestigious medical schools and lucrative metropolitan private practices. At the other end are inner-city hospitals and rural areas with no doctors. Graduates of foreign medical schools mostly provide care at the latter end of the spectrum. The fact that after a few years they move to more attractive practices and careers cannot be held against them. They have paid their dues, and they want to be part of the American dream, for themselves and their children.

Graduates of foreign medical schools fulfill a need created by the very medical system that is becoming increasingly hostile toward them. If a surplus of physicians is truly an important issue, the factors that lead to reliance on graduates of foreign medical schools should be identified and eliminated. Bashing of graduates of foreign medical schools should stop.

Mukul Chandra, M.D.
University of Texas Medical Branch, Galveston, TX 77555-0570

Author/Editor Response

Mr. Iglehart replies:

To the Editor: Dr. Bradley's assertion that the United States has a responsibility to finance the training of foreign-born physicians who would then return to their homelands to practice would be a credible argument if it reflected the current situation. Unfortunately, it does not. Mullan et al. estimated that 70 to 75 percent of all graduates of foreign medical schools pursuing advanced training in the United States “eventually enter practice” here.1 Moreover, such physicians enter subspecialties at a disproportionately high rate and thus contribute less to the growth of the pool of generalist physicians.

Dr. Chandra has accurately depicted the trade-off that the United States has fashioned in relation to foreign-born physicians who enter graduate medical-education programs here. Unfortunately, this bargain serves individual doctors and a few U.S. teaching hospitals far better than it does the countries (India, the Philippines, Pakistan, the nations of the former Soviet Union, China, and Egypt) from which most of these physicians emigrate. These countries subsidize the undergraduate education of these students only to see them emigrate to the wealthiest nation on earth. This policy may help provide care to our indigent population, but it mostly serves to underscore the bankruptcy of U.S. health care policy in relation to the poor.

If most foreign-born physicians returned to their homelands after completion of graduate training here, the United States would make an enormous contribution to these countries rather than drain them of some of their most talented young people. Meanwhile, we should draft a more responsible health care policy, as Dr. Bradley suggests. One logical place to begin would be to expand the National Health Service Corps, a program that almost died during the Reagan administration but that came back to life in the early 1990s with bipartisan congressional support. The program finances scholarships for medical and other health care students and loan-repayment contracts for primary care clinicians.2 As of September 30, 1995, there were 2225 clinicians in practice through the program, including 1267 physicians.

John K. Iglehart

2 References

1. 1

   Mullan F, Politzer RM, Davis CH. Medical migration and the physician workforce: international medical graduates and American medicine. JAMA 1995;273:1521-1527
   CrossRef | Web of Science | Medline

2. 2

   National Health Service Corps. Report to the Congress for years 1990–1994. Washington, D.C.: Department of Health and Human Services, 1995.
   

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