As hospital emergency rooms and intensive care units swell with patients infected with the COVID-19 virus, political leaders coordinating responses in “hot spots” are asking doctors and other medical professionals in parts of the country less impacted by the pandemic to come to the rescue. New York Governor Andrew Cuomo issued such a plea the other day. Governors are issuing executive orders that relax occupational licensing restrictions on the free movement of health care practitioners. Some are also expanding the scope of practice of various licensed health care professionals, permitting them to provide the health care services they are trained to do. Meanwhile, a large pool of doctors trained at excellent institutions outside the borders of the U.S., referred to as International Medical Graduates (IMGs), goes untapped. A cumbersome approval process begun in the 1950s places daunting obstacles in the way of IMGs who want to practice in the U.S. and keeping tight reins on the already short supply of doctors.
The process is overseen by the Educational Commission for Foreign Medical Graduates. The ECFMG is a private non‐profit organization established in 1956 to “evaluate the readiness” of IMGs to enter graduate medical education programs (residencies and fellowships) in this country. (Graduates of Canadian medical schools are not considered IMGs.) The American Medical Association and the American Hospital Association soon recognized the ECFMG as the standard for evaluating IMGs entering the U.S. health care system and serving patients in its hospitals. The ECFMG obtained responsibility for visa sponsorship of Exchange Visitor physicians (J-1 visas).
Graduates of medical schools outside of the U.S. and Canada must become certified by the ECFMG before they can enter U.S. graduate medical programs. This means they must receive their diplomas from an ECFMG‐approved medical school, pass steps 1 and 2 of the 3‐step U.S. Medical Licensing Examination, complete a graduate medical education program, and then pass Step 3 of the USMLE.
State licensing requirements vary with regard to IMGs. Some require more years of graduate medical education training than they require from graduates of U.S. and Canadian medical schools before they issue them a license. Most issue licenses to graduates of U.S. and Canadian medical schools after applicants have passed step 2 of the USMLE and several don’t require these licensees pass to step 3 in order to maintain their license.
Yet IMGs who received their diplomas a while ago and have been practicing medicine outside the U.S., often for several years, must go through the same process as fresh medical school graduates. This means they must get ECFMG certification—including taking and passing all three steps of the USMLE—and go through a residency training program all over again. Then they must apply for state medical licenses. Many experienced foreign‐trained doctors take positions in ancillary medical fields, such as nursing, lab technician, and radiology technician instead of starting all over again. Some even work as waiters or taxi drivers.
I worked with an Operating Room Technician (the person who passes instruments to the surgeon) from Syria who had impressed me with his knowledge and focus on the operations I perform. He would occasionally offer an excellent suggestion or insight during a technically challenging segment of the operation. I soon learned that he had been a general surgeon who practiced in Syria before coming to the U.S. He decided to divide his time between working as an OR tech and starting up a Middle Eastern restaurant rather than starting all over again.
To be sure, the quality and approach to the practice of medicine varies in different parts of the world. In some parts of the world doctors deal with a different constellation of health problems than exist in the U.S. and some may have less exposure to the technological advances that abound in the U.S. health care system. There may also be cultural differences that affect their understanding and communication with American patients. For this reason, certification organizations like the ECFMG, specialty boards (e.g., American Board of Surgery, American Board of Internal Medicine), as well as rating and evaluation services, play an important role in providing critical information to consumers of health care.
In Canada the provinces have domain over medical licensing. Some provinces grant licenses to experienced immigrant primary care physicians from certain countries to practice without having to repeat the residency program. Some also welcome medical specialists who are trained and experienced in certain other countries without having to start over.
To address the current public health emergency, several states are granting reciprocity to health care practitioners licensed in other states. Three states—Arizona, Pennsylvania, and Montana—reformed their occupational licensing laws to grant reciprocity well before the advent of COVID-19 pandemic. As I have said before, these reforms should apply to all the occupations and should be permanent—not just temporary responses to the public health emergency.
In the same spirit, states should consider granting reciprocity to health care practitioners licensed in certain other countries with reputations for quality medical education. Meanwhile, certifying organizations should include applicants’ active clinical experience in other countries as a factor in certification criteria. Finally, these changes need to be accompanied by liberalizing immigration rules for medical professionals and their families now—waiting for overall immigration reform to happen will not address the problem fast enough.