By David J. Skorton, MD
Originally posted on February 20, 2013
With President Obama making immigration reform a key focus of his second term, and the issue attracting strong bipartisan interest in Congress, the time is right to overhaul the system in ways that serve the national interest and address our responsibilities as citizens of a shared world.
As I noted in the Huffington Post two years ago, we need to match our policies to the realities of 21st century innovation and communication, where ideas and jobs more and more easily transcend borders. While we need to safeguard our borders and maintain national security, ultimately, in collaboration with other nations, we need to move toward a world where talented individuals are able to move more easily among countries, creating new networks of knowledge and practice that adapt to local needs while harnessing the power of knowledge no matter where in the world it is found.
A complex area that involves movement of individuals among nations is health care. The U.S. already employs a substantial proportion of physicians (about a quarter) and other health workers (about a fifth) who were educated or trained overseas, and we could easily employ more of them without taking jobs away from Americans. In fact, as the nation ages and more previously uninsured individuals seek treatment under the Affordable Care Act, the health of millions of Americans may depend on the availability of more physicians and other health workers from abroad.
The U.S. already faces a shortage of physicians in rural and inner city areas. The Department of Health and Human Services estimates that as of December 2012, there were 5,848 “Primary Medical Health Professional Shortage Areas” in the U.S. and that it would take an additional 15,928 physicians to adequately meet the primary care medical needs of people in those areas.
The American Association of Medical Colleges (AAMC), on whose board of directors I serve, projects that there will be a shortage of over 90,000 physicians — including 45,000 primary care physicians — by the end of the decade, “leaving patients with cancer, Alzheimer’s disease and dementia, hip fractures and other ailments without immediate access to necessary care.”
American medical colleges are increasing their enrollments, and additional medical colleges are being established. By 2016, the AAMC predicts, medical school enrollment will have increased by 30 percent over 2002 levels. Yet even this substantial increase may not be adequate to meet increasing national demand.
Granting more H-1B visas to international medical graduates who have already completed U.S. residencies in high-demand specialties, including primary care, and who agree to practice for a prescribed length of time in underserved areas, would meet a pressing national need while ensuring that these physicians augment their prior medical training with additional training and practice in the U.S. This experience would serve them well, whether they ultimately obtain a green card and stay here or decide to return home after their service in the U.S. is complete.
And while we’re removing the barriers to physician immigration to benefit from the skills and knowledge we need from a global pool of talent, let’s also revisit the cap on graduate medical education funded through Medicare. Federally funded residency positions, which are especially critical for academic medical centers, have been frozen at 1996 levels for more than 15 years. This has created a significant bottleneck for new MD graduates — from the U.S. and elsewhere — seeking to complete the residency training that is a prerequisite for independent medical practice in the U.S. The AAMC recommends that the number of federally supported residencies be increased by a minimum of 4,000 a year — with careful attention to changing demographics, the needs of specific states and regions and the evolving ways in which heath care is being delivered.
Of course, while the U.S. and other developed nations benefit from international medical graduates — and the international graduates themselves often benefit from the opportunity to practice medicine using more advanced technologies — developing nations lose the highly trained physicians and other health care workers they desperately need and in whom they often have invested substantial resources. The shortage of health professionals in the U.S. pales in comparison to the worldwide need, which the World Health Organization puts at about 4.3 million. Especially in sub-Saharan Africa, the loss of trained physicians and other health workers to the West is making it even harder to secure the health of their citizens.
The flow of doctors and other health professionals from the developing to the developed world is so significant that the 193 member states at the World Health Assembly in May 2010 adopted a voluntary WHO Global Code of Practice on International Recruitment of Health Personnel. The code aims to develop sustainable health systems, protect the human rights of migrant health workers, provide technical and financial assistance for health care personnel development in low- and middle-income countries, and “facilitate circular migration of health personnel, so that skills and knowledge can be achieved to the benefit of both source and destination countries.” As of December 2011, almost 70 nations had designated a national authority to exchange information on health worker migration and implement the code.
More and more, we are appreciating the need for strong health care systems across the world to ensure better health in any specific location. The U.S. has stepped up to the challenge through theMedical Education Partnership Initiative and other programs that are supporting local health ministries and academic centers in Africa with technical assistance in order to increase the number and quality of health professionals and encourage them to remain in their own country.
Private initiatives are also playing important roles. My own university, for example, operates a branch of its Weill Cornell Medical College in Doha, Qatar, with support from the Qatar Foundation. Students from Qatar, as well as from several other nations, earn a Cornell MD degree through the program. They have had excellent success in securing residencies in the U.S., as well as at the Hamad Medical Center in Qatar. We also have a close relationship with Weill Bugando Medical Center in Tanzania, where faculty from the Weill Cornell Medical College are on site to help train doctors to practice in Tanzania. Although these programs are still relatively small, they offer models for building capacity for health care in the Middle East, Africa and elsewhere.
Moreover, a growing number of American medical students and young physicians are seeking international experiences as a way to act on the commitment to social responsibility and service that originally drew them into medicine. An increasing number of international medical graduates who immigrated to the United States are also returning to their home countries periodically to help strengthen the health care systems there — even if they choose to practice primarily within the United States (see “From Brain Drain to Mutual Gain: Sharing the Benefits of High-Skill Migration” and “Social Accountability in Health Professionals’ Training”). The AAMC Global Health Learning Opportunities Collaborative facilitates global mobility for students pursuing clinical, research, or public health electives outside their home country.
As a nation, and certainly on a global scale, we are still a long way from having a seamless movement of people, knowledge and ideas across national borders. But I predict that within the lifetimes of those who are now earning their medical degrees, a new model of “brain circulation” will replace the “brain drain” that is holding back the health care systems of the developing world and preventing our own country from adequately meeting the health care needs of our citizens.
To move us closer to that day, removing the barriers that prevent global talent from reaching our shores through comprehensive immigration reform would be a positive start. As President Obama said in his Inaugural Address last month, “Our journey is not complete until we find a better way to welcome the striving, hopeful immigrants who still see America as a land of opportunity; until bright young students and engineers are enlisted in our workforce rather than expelled from our country.”
Through enlightened immigration policies, we can address our physician shortage and be a beacon for the rest of the world.