At a time when primary healthcare in the United States is more dependent than ever on foreign-trained doctors, the programs that permit those doctors to practice in this country face an uncertain future under the Trump administration.
Uncertainty, red tape, and anti-immigration policies have some primary care physicians contemplating leaving the U.S. for more welcoming countries, while some international medical graduates are reconsidering whether they want to practice here.
A decline in the number of international medical graduates would worsen the already serious shortage of primary care doctors, particularly because they tend to choose primary care specialties and many of them work in medically underserved areas.
“We are making healthcare more accessible, but we are subject to such uncertainty that some of us are rethinking whether we have a future here,” says Ram Sanjeev Alur, MD, an Indian-born internist in Marion, Ill., who’s thinking of leaving the country.
The impact of international medical graduates
According to the American Immigration Council (AIC), just over one-quarter of doctors (247,449) in the U.S. were foreign-trained as of 2017, meaning they received their medical degrees from schools outside the country. A small percentage are U.S. citizens who went abroad to medical school, but most are not.
The percentage of these doctors in primary care is even higher. The same study found that nearly a third (31.8 percent) of physicians specializing in family medicine, internal medicine, or pediatrics are foreign-trained.
International medical graduates are more likely to serve in low-income areas, as well. More than half (53.4 percent) of all such doctors work in areas where the population has a per-capita income of $30,000 or less, according to the AIC. In areas where per-capita income is below $15,000 a year, these graduates account for 42.5 percent of all doctors.
In areas where 75 percent or more of the population is non-white, 36 percent of the doctors are trained outside the U.S. They also make up greater shares of all doctors serving populations with lower educational attainment.
With the Association of American Medical Colleges (AAMC) predicting a shortage of primary care physicians of up to 49,300 by 2030, the AIC and other organizations are raising concerns about the future of primary care.
“International medical graduates serve a very important purpose in providing primary healthcare in this country, particularly in light of the physician shortage,” said Ana Maria Lopez, MD, MPH, FACP, president of the American College of Physicians (ACP). The ACP and other healthcare organizations have lobbied Congress and regulators to ease some policies that made it more difficult for internationally trained physicians to practice here.
One couple's story
The difficulties of those policies are well known to Narayanan Krishnamoorthy, MD, and Chitra Mony, MD, a husband and wife practicing in Tallahassee, Fla. They went to medical school in India, then trained in Scotland.
In 2006, Mony matched with Tallahassee Memorial HealthCare’s residency program. A year later, Krishnamoorthy matched with the same hospital and joined his wife in Florida. Mony, who entered on a national interest visa, was required to work for three years in an underserved area. Krishnamoorthy switched from an H-1B visa, which binds him to one employer, to an H4 visa Employment Authorization Document (EAD) work permit, which allows him more flexibility in working as the spouse of an H-1B visa recipient. They have both applied for green cards to become permanent residents but are in a quota-restricted waiting line that could take decades.