The US Health Care System Needs Immigrants


as a recent eight-nation bracket
tournament in the new york times showed and i’ve discussed that a lot many
people think the united states healthcare system has a lot of problems
so it seems reasonable to think of policy changes that make things better
not worse making it harder for immigrants to come here to practice
medicine would fail that test that’s the topic of this week’s healthcare triage by any objective standard the United
States trains far too few physicians to care for all the patients who need them
we rank towards the bottom of developed nations with respect to medical
graduates per population when physicians graduate from medical school they spend
a number of years in a residency program I did not enjoy mine although they have
their degrees we still require them to train further in the clinical
environment to hone their skills residents are more than learners though
they’re doctors they fill a vital role in caring for patients in many hospitals
across the country we don’t have enough graduates even to fill residency slots
this means that we’re reliant on physicians trained outside the country
to fill the gap a 2015 study found that almost a quarter of residents across all
fields were foreign medical graduates and more than a third of residents and
sub specialist programs were even training aside foreign medical graduates
are also responsible for a considerable share of physicians practicing
independently today about a quarter of all doctors in the United States are
foreign medical graduates as in many other fields foreign medical graduates
work in many of the areas that other doctors find less appealing more than
40% of the American primary care workforce is made up of people who
trained in other countries and moved here more than half of all the people
who focus on caring for older people or geriatricians are foreign medical
graduates as well as if this weren’t enough foreign medical graduates are
more likely to practice in geographic areas of the country where there are
physician shortages like non urban areas and they’re more likely to treat
Medicaid patients – as a physician who graduated from a domestic medical school
I’ve often heard others disparaging doctors who went to medical school
outside this country as if they were inferior those complaints are not
supported by data study from health Fair’s in 2010 found that patients with
congestive heart failure or myocardial infarction had lower mortality rates
when treated by doctors who were foreign medical graduates another from earlier
this year in the BMJ found that older patients who were treated by foreign
medical graduates had lower mortality as well even though they seemed to be
in general in other words foreign medical graduates take care of patients
who appear to be more ill but seem to achieve better outcomes a recent study
in annals of internal medicine shows that these graduates are also
responsible for a significant amount of teaching of the 80,000 or so academic
physicians in this country more than 18% were foreign medical graduates more than
15% of full professors and medical schools in the u.s. were educated
elsewhere most often in Asia Western Europe the Middle East Latin America and
the Caribbean foreign medical graduates also do a lot of research although they
are ineligible for some NIH funding which is granted only to citizens of
this country they still manage through collaboration to be primary
investigators on 12 and 1/2 percent of grants they led more than 18% of
clinical trials in the US and were responsible for about 18% of
publications in the medical literature I spoke to the lead author of the study
Dhruv cooler who’s a physician at New York Presbyterian Hospital and a
researcher at Weill Cornell he said and I’m quoting our findings suggest that by
some metrics these doctors account for almost one-fifth of academic scholarship
in the United States the diversity of American medicine and the conversations
ideas and breakthroughs this diversity sparks may be one reason for our
competitiveness as a global leader in biomedical research and innovation the
United States is not the only country that relies on doctors trained or
educated in other countries we’re not even the country with the highest
percentage of such physician according to data from the OECD almost 58 percent
of physicians practicing in Israel are foreign medical graduates about 40
percent of doctors in New Zealand and Ireland
we’re also trained outside those country because of the sizes of those nations
even though the percentages of foreign medical graduates are higher there the
total numbers aren’t as high as in the u.s. though in 2015 the OECD estimated
that the United States had more than two hundred and thirteen thousand foreign
trained doctors and no other country comes close Britain had about 48,000
Germany about thirty-five thousand and Australia France and Canada had between
22 and 27 thousand I’ve listened to people tell me stories of physicians who
leave Canada because they were dissatisfied about working in a
single-payer health care system that might have been true debt
to go but in the last 10 years that number has dropped precipitously the
number of Canadians returning to their country to practice may actually be
higher than the number leaving and although many feared the coverage
expansions from the Affordable Care Act might lead to an overwhelmed physician
workforce that didn’t happen that doesn’t mean that America doesn’t have a
shortage of physician services as we’ve discussed in previous episodes
especially when it comes to the care of the oldest the poorest and the most
geographically isolated among us even though we know foreign medical graduates
care for these patients just proportionally we make it very difficult
for many born and trained elsewhere to practice here some Americans need those
doctors desperately all the evidence seems to suggest that policies should be
made to attract them not deter them sometimes talking about drugs and sex
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78 Replies to “The US Health Care System Needs Immigrants”

  1. Are physicians going back to Canada because the single payer system is better now or they are no longer incentivized to practice in other countries? (E.g. ACA makes US less attractive for foreign physicians) #nopolitics

  2. I am a FMG but not an immigrant. There are lots of us because US medical schools don't have enough spots. Calling us all immigrants is not accurate. Ross University alone places about 800 residents per year and most of them have US citizenship.

  3. Easier to the the pay cut to be an academic physician or to work in under served areas if one has little or no student debt. The new members of our practice — academic hospitalists– seem to have around $350k in student debt.

  4. On the one hand, I agree that doctor shortages are a major problem, and that not enough people have the ability to see a doctor when needed. I live in Atlanta GA, and have friends who work in Grady Hospital – the lines to see a doctor are appallingly long, with some services requiring MONTHS of advance notice! And that's in the middle of one of the largest and busiest metropolises in the South; how bad must it be out in the middle of the Appalachian mountains?! We need more doctors and BADLY.

    However, we must be very cautious in how we approach this: taken too far, rampant outsourcing can make it harder to get local people to become doctors due to lack of available positions preventing them from being able to pay back the massive loans they'd incur, which makes fewer people want to be doctors and necessitates more doctors being brought in to fill the gaps in a vicious cycle. We've seen this kind of thing adversely affect other industries such as software development; there's no reason it couldn't happen to medical practitioners, as well.

    I'm not sure what the best solution is, here. Perhaps a small, short-term boost to immigrant doctors while also changing the education system to attract local medical students…?

  5. Yes, may so be it, but the problem is that sure, there will be medical trained immigrants or immigrants that aspire to study to the medical field BUT that also means that those people among the rest of the immigrants need to not only offset the current shortage in the USA, they also have to offset the medical needs of the other immigrants, thats not a guarantee. What if there comes more immigrants that have more medical needs, or load the healthcare system even more than what the medical immigrants can support? Then not only are you back at square one where you need even more medical, you also risk increasing the medical load in the US.

  6. As someone who works in a clinical setting, I would argue we don't just need foreign docs. Large numbers of nurses, techs, and auxiliary services staff come from other countries as well

  7. Going to take a bit of a leap in an assumption here. Two grounds, one I live in England, two it's personal experience.

    Instead of encouraging many people of going into medicine, people get told that it's hard, unsociable, and unpleasant. Might have truth to it, but this along with the super high costs is probably putting a lot of people off.

    So stop doing that maybe?

  8. Well hey, good thing the RAISE Act prioritizes skilled immigrants, like doctors, over others who may end up on medicaid (patients who are more likely to use more care without any improved outcomes).

  9. US absorbs the middle class of other countries? Golly, perhaps making med school free would alleviate the problem and also help other countries.

  10. Explains why I ask for a foreign trained doctor when I make a doctors appointment. They will get pissed when they hear that I’ve missed meds or have been withheld.
    American trained will withhold my meds and tell me I will just get a little tired.
    Took 4yrs when I was a kid before I saw a foreign trained doctor and we weren’t even in the room 5 minutes and he had me taken straight down to do tests. He was surprised I was moving around.

  11. US med school is both massively expensive and sets limits on admission that are lower than physician demand. Seems like that would be the biggest cause of the low percentage of domestic trained doctors.

  12. It’s because of how expensive college is. The price is way to high, we can’t just give grants. Colleges need to lower prices.

  13. are you planning to do a video about the influence of the rest of the immigrants on the us health care system? i don't know what percentage of immigrants are qualified doctors/nurses but i guess it's in the single digits. what about immigrants without college degree whats their effect on the healthcare system?

  14. One of the issues you didn't mention is brain drain, when countries like the US recruit highly skilled people (like doctors) from other countries, leaving their country of origin with a shortage of providers. Free movement of people is important and it is understandable to want to pursue 'The American Dream' and possibly make more money, but at some point it becomes a question of ethics.

  15. how about training your own doctors rather enticing other countries doctors away? it's not like all other countries have a surplus of unneeded doctors.

  16. This could be solved by not limiting the practice with a monopoly on licensing. This could also be solved by not forcing everyone to pay for everyone. This would solve the real issue, which is a shortage due to various policies.

  17. Canada has a lot of foreign doctors. Some become doctors in their country of origin, some immigrate here as a child and then subsequently go to school to become a doctor so that they can provide a better life for themselves and their family. I have never doubted the competency of any foreign doctor or any foreign medical professional for that matter. The South African, other African, Chinese, Indian, and Carribean doctors I've come in contact with have all been wonderful.

  18. Look at it this way most of the dr's willing to move to another country are the high flyers. America has a very large shortage of Drs comparatively to it's population.
    If you ever want health care for all; your going to need more dr's than your universities can train.
    So why would make it harder?

  19. How about paying for doctors to go to school like Germany. Perhaps the cheaper medical schools would allow for more graduates. Of course, that would drive the Medical College-Industrial Complex crazy.

  20. Relying on migrant workers just sucks all the skilled workers from poorer countries.
    Those poorer countries then have worse service.
    This applies to more than just healthcare.

  21. This doesn't seem to have info on people who were born domestically and trained internationally. Need to figure out 2×2 data points: Born domestically or foreign, and trained domestically or foreign. Are these foreign medical graduates people who were born locally but only got into school overseas? What about people who were born elsewhere and moved domestically to train and later work?

  22. Another great video from Dr. Carroll. I want to point out that the US has a supply of physicians that very similar to the UK and Canada, or about 2.5 physicians per 1,000 people. (See link to WHO map below.) But we have a far greater proportion of specialists and far fewer primary care providers. This drives up costs and, counter-intuitively, results in poorer quality care. A good primary care system produces better population health and the US doesn't have that. We could make a difference by changing medical education to emphasize primary care rather than specialty care and by rewarding primary care providers rather than specialists.

    http://www.who.int/gho/health_workforce/physicians_density/en/

  23. How about investing in opening new med schools across the country so we can also produce more medical professionals?! We have TONS of qualified Med school applicants, we just don’t have enough schools to take a huge majority of them. Although in the short term, we could definitely use some doctors from other countries, it’s pretty ignorant to not acknowledge we can fix the doctor shortage on our own if we do the right things.

  24. I think something worth mentioning is that once you complete your residency in one country, you often cannot practice in other countries. So if your specialty isn't available in your home country, you already don't have the option of returning to that country after residency since they often won't accept your residency as meeting their requirements. If there was a better way to certify boards and residencies across all countries, then doctors would be more free to move to where they are most needed.

  25. Uhh… why not just make it easier for Americans to go to med school? Is it that there is no interest? I really doubt that. This seems very stupidly political. Don't do that. I don't like unsubbing from channels just because they lose sight of reality for a narrative.

  26. I wish there was a inbetween votw for this. As it highlights well some of the problems but, what about the rising education cost to domestic students vs foreign ones. I think its become the thing for foreign grads ro go back to home or another place for more money, respect and easier policies to deal with. Domestic students fail mostly due to the debt/cost. I may be wrong but with the ammount of citezens we have we should be able to bridge the gap. And sprinkle in more foreign mds as well. Policies across the board need change. Not so much more foreigners as md.

  27. I’m an American citizen born and raised, but I went to a Caribbean medical school. Granted I struggled in my Step scores and I am taking a Masters in Public Health, as well as doing research publications. But that’s just the thing. I have two strikes against me: non-competitive scores and foreign medical graduate (FMG). Today, the state of Missouri is trying to put to practice the new Assistant Physician Law. Also, I don’t mind working as a “Physician Assistant” until the time I get residency. And yet I am considered “not qualified” to work as an PA despite the nations need to work in underserved areas.

    Did I also mention I also did all my rotations in the US?

    The point is, I think it’s important to point out that FMGs are pressured to do research to be more competitive in residency applications. And because we have the FMG stigma, we also have to work twice as hard to “prove ourselves” in our rotations.

    I did my mistakes in the USMLE, and I learned from them and I even finished even Step 3, an exam that caused tragedies for some residents to be kicked out. I am still passionate about practicing and seeing patients and I’m willing to pay more than 10 grand on my ERAS just to be able to get a few interviews in hope that one program takes me this March. Until then, I’m in limbo, and I am preparing for plan B and plan C, in case plan A doesn’t work for me.

    Anyway, thank you for the video. I think the US government does not realize the important of residency and they do not seem willing to fund more hospitals to open up.

    Also, one last hurdle. I’m a US citizen. Shouldn’t I be granted the opportunity to join the Armed Forces and serve my country in hopes that I get a residency. The answer is: only if you’re a domestic graduate, not an FMG. When I get into residency, then I can only contact them. So I’m stuck between a rock and a hard place. But if I get in this March, you’ll be hearing from me again with this slogan: don’t give up.

    I hope that rings true for me, if not this yea (this is my third time applying), then maybe next year.

  28. Its clear that the AMA played a key role in limiting the access to medical degrees while lobbying aggressively to change state laws to make their services more in demand. I do not think that we shouldn't look to bring in more foriegn medical trained people, but the doctor shortage and quality problems associated with it can be directly attributed to their lobbying power.

  29. America should be hiring AMERICAN doctors! I'm not a med student and I don't know any med students, so my opinion on the matter means very little. My sister is a Dental Hygienist, tho.

  30. 2:16 One of the main reasons the US scores worse than most other "developed" areas is who is being put there
    https://www.youtube.com/watch?v=vFgwvcixzc8

  31. Wondering if the cost of US medical schools has something to do with this. My primary reason for not having any interest in medical school is that I'm not about to borrow $200K just for tuition. Being a primary care provider in a town of 30,000 or less isn't going to pay that off on a reasonable timeline. This also might explain why we have such poor distribution of physicians in this country. Perhaps a video about paying for medical school is in order?

  32. Correction: Skilled Immigrants …not just immigrants–we don't need unskilled, uneducated welfare immigrants who never plan on working, or those with dubious backgrounds. Also, while I don't disagree with this video…don't other countries need medical professionals? Can't imagine them having a surplus and are trying to get rid of all of their doctors. The more that are incentivized to come here for a better life and higher standard of living…the further it lowers the standard of living for those countries they come from because we'd be taking them away, since everybody everywhere needs medicine and medical professionals.

  33. Your video lacked any examples on how the current or proposed immigration policies hinder foreign medical workers from entering the US. The current system has a cap on the amount of workers and I think it needs improving. The immigration policy proposed by Trump would make it easier for more educated individuals to enter the US. I understand that it isn't popular because they are talking about putting restrictions on family member visas. I think as a whole it will be beneficial to have more skilled foreign workers here and I think that most people would agree. Hopefully there can be a bi-partisan agreement on how that can work without open the flood gates wide and letting anyone and everyone in. I doubt that our Congress can agree on anything.

  34. Doctors are usually high quality immigrants so I don't think any US citizen no matter their political preference would object if they immigrate to the US. Just have some standard though, there's a difference between Oxford Medical School and 'Al Jazeera Online Course for Healing'.

  35. I'm absolutely flabbergasted at the number of people who don't understand that the cost of medical school has nothing to do with the physician shortage and that importing foreign treasured physicians is not taking jobs away from citizens.

    To the first point, there are far more qualified applicants to medical schools each year than there are openings in medical schools. We have both too few medical schools and class sizes that are too small to support our need for doctors. This is a large reason why medical schools can charge so much- demand is high and there isn't any competition. Also, no regulations to stop them!

    To the second point, not sure why people don't understand the definition of the word shortage. Bringing in foreign doctors doesn't take away jobs from citizens, because we don't have enough doctors to fill all of the positions available. The only thing you could possibly argue is that it increases competition for the most desirable jobs. In my opinion, let the best doctor win. If I need brain surgery, I'd rather have the most competent doctor available doing that, regardless of their country of origin.

    I know some of y'all are afraid of immigrants and also of opinions you disagree with, but stop being such triggered cry babies. Actually look at the evidence before you go throwing a tantrum about LIBERAL PREJUDICE and IMMIGRANTS STEALING OUR JOBS 😭. Reacting this way supports our shitty political system that wants to keep the people divided and fighting each other instead of actually fighting for a better future.

  36. honestly, after reading some of these comments, i really won't try to get into a residency programme in the US. i get insulted by rude patients everyday already, i don't need to take several tests, pay thousands of dollars and take 7 hour flight to have that

  37. great video Dr. Carroll. Have you listened to this podcast about nurses in America by Freakonomics? http://freakonomics.com/podcast/nurses-to-the-rescue/ It's a good one and fits into this theme of filling holes that domestically trained doctors don't by giving nurses more scope to practice

  38. I can think of two instances off the top of my head where foreign trained professionals are prevented from practicing in the States unless they retook the same classes and certs. Kinda baffling.

  39. I hated memorization. That's why I am a chemist, not a doctor. I have a good memory and when it comes to technical stuff I have damn near total recall. But forcing students to memorize stuff with flash cards will weed out motherfuckers like me. Also, pre-med students were notorious and implaccable cheaters. That may be unique to my college, however.

  40. Just a short note about the OECD stat regarding Israel- a large number of Soviet (and smaller number of European and American) Jewish doctors moved to Israel in the early 90s which contributed greatly to the 58%. In addition, in recent years there has been an influx of Israeli students who are studying medicine abroad – mostly in central and eastern Europe since it's easier to get into med school there and overall living/studying costs are similar or even lower than they are in Israel.

    Both those push the "foreign medical grads" stats up, but also can mislead since they are Israeli citizens who merely studied abroad (in the more recent case) or are Jews who lived in the USSR and who fled to Israel after the fall of the Iron Curtain.

  41. It would occur to me that shortage of anything cost more in basic economics, so……….bring on the immigrants!

  42. Could I ask you all to review and edit the captions for these videos? They are fantastic but my students with hearing loss struggle to use the resource. Thank you for all you do!

  43. Chile also relies heavily on foreign trained doctors, especially on primary care. My husband currently works in primary care (before the residency) and he’s one of 3 Chilean doctors in the facility; I think the rest are all foreigners.
    Also, we’d look into going to the US for a subspecialty program but that prospect looks much worse now with the political climate there…

  44. I know the USA is having a bit of a healthcare crisis and Americans make , but could Healthcare Triage have more videos on general health issues than current issues for the USA. Out of your videos for this month 9 are about USA centric issues and only 4 are general health topics. I can not imagine these videos will be relevant in two years people in USA, just as they are not relevant for me here in Australia now.

  45. Biden says the American taxpayers are
    OBLIGATED to give
    illegal aliens FREE healthcare

    Listen and share….

    https://youtu.be/IQh4sY9IqzU

  46. The title of the video is a fallacy. The facts are that highly trained, educated and licensed people have difficulty finding jobs mostly due to an influx of H1-B visas. At this time, it has become so bad, that medical school graduates, who spent years of study and hard work, do not match to residencies. This is because the number of medical schools keep growing as does the number of foreign students accepted into residencies, leaving US born and educated doctors stuck mid career path with hundreds of thousands of dollars in debt. Furthermore, affirmative actions has a huge impact on who does and who does not get into medical school. Minority students are admitted with much lower GPAs and MCAT scores, turning away many highly qualified American students of european descent. This may reflect in the study mentioned in the video. Foreign doctors have fewer requirements, fewer years of study and previous studies compared demonstrated this deficit in testing and outcome compared to US doctors. If current studies no longer demonstrate this, perhaps we should be looking at causation. In addition, the origin of foreign physicians is also a factor. East Asian students are meritocratic in their admissions while south asians have had many cheating scandals in med schools and purchasing med schools seats is a common practice. This is also occurs in Caribbean and South American systems, which was excluded from the study . more on that later
    There is no link to the reported study from Health Fairs and NYT is not a credible source
    And now for the bad news. Specifically BMJ stated : In the United States, patient death rates are lower for internationally trained graduates than for graduates from a US medical school, despite international graduates caring for patients with higher rates of chronic conditions, finds a study published by The BMJ today.
    However, it appears these factors were adjusted for:
    We adjusted for patient characteristics, physician characteristics, and hospital fixed effects (ie, hospital specific indicator variables included as covariates). Patient characteristics included age in five year increments (65-69 years through 90-94 years, and ≥95 years), sex, race or ethnic group (non-Hispanic white, non-Hispanic black, Hispanic, other), primary diagnosis (defined by Medicare severity-diagnosis related group), Elixhauser comorbidity index31 (27 coexisting conditions), median household income estimated from residential zip codes (in deciles), an indicator for dual Medicare-Medicaid coverage, year indicators, and day of the week. Physician characteristics consisted of age in five year increments (<35 years, 35-39 years, and so on through 65-69 years, and ≥70 years), sex, and patient volume (number of Medicare beneficiaries treated as a continuous variable with quadratic and cubic terms to allow for a non-linear relationship). Hospital fixed effects account for both measured and unmeasured characteristics of hospitals, allowing us to effectively compare patient outcomes between international and US medical graduates within the same hospital.323334

    But there appears to be bias in these adjustments:
    … third,to account for the influence of international medical graduates who were US citizens, we excluded international graduates who graduated from medical schools in Central America and the Caribbean, because three quarters of US citizen international medical students graduate from medical schools in these countries.113839Fourth, since differences in length of stay, utilization of care (total part B spending per hospital admission), or discharge location might explain differences in patient outcomes between the graduates, we further adjusted our regression models for these variables. Fifth, to deal with the impact of unobserved care preferences of patients, we excluded patients with cancer and patients who were discharged to hospice care.40 Sixth, as international graduates might be more or less likely to work as intensivists in intensive care units, we excluded hospitals with a medical intensive care unit. Seventh, it is possible that residents bill Medicare claims on behalf of their attending physicians at teaching hospitals, and differences in patient outcomes might be related to the quality of care delivered by residents. To address this, we stratified our sample by teaching status of hospitals (major teaching, minor teaching, and non-teaching hospitals), and within each group we compared international medical graduates with US medical graduates (adjusted for patient and physician characteristics and hospital fixed effects). Finally, we examined whether patient outcomes varied by countries where international medical graduates were trained, after restricting to eight countries with the largest number of international medical graduates going to the US (India, Pakistan, Philippines, Syria, Nigeria, Mexico, Egypt, and China) to avoid unstable estimates (see supplementary appendix 1 for more details).

    Results
    Hospital, physician, and patient characteristics of international graduates

    Overall, 44.3% (19 589/44 227) of general internists in the US were international medical graduates. Among the internists, international graduates tended to be younger than US graduates (46.1 v 47.9 years, P<0.001; table 1⇓) and were more likely to work in medium sized, non-teaching for profit hospitals, and hospitals without intensive care units.

    So basically,  you are only comparing the lower rung of US educated physicians to IMG.  Hospitals with intensive care have been eliminated from this study after specifically stating that IMG were less likely to work in hospitals with ICU as well as less likely to work in teaching hospitals (strangely the authors state that IMG " might be more or less likely to work as intensivists"  in ICU earlier) . Many international doctors come from latin america but the IMG from central america and the Caribbean have been eliminated completely from the study.   This is a biased study

  47. I can not locate the source your cite: Health Fairs? The link to the NYT is not a credible source.

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