NYT article about IMG's

lilycat · Oct 27, 2005

Interesting NY Times article about the exodus of doctors from the "third world" to the four wealthiest countries...

Devastating Exodus of Doctors From Africa and Caribbean Is Found

By CELIA W. DUGGER
Published: October 27, 2005
A new study documents for the first time the devastating exodus of doctors from Africa and the Caribbean to four wealthy English-speaking nations, the United States, Britain, Canada and Australia, which now depend on international medical graduates for a quarter of their physicians.

The findings are being published today in The New England Journal of Medicine. The study is likely to fuel an already furious debate about the role the developed world is playing in weakening African public health systems that have already been hit with pandemics that have shortened life expectancies in some countries.

Dr. Agyeman Akosa, the director general of Ghana's health service, said in a phone interview from Geneva, where he is attending a World Health Organization forum on the global medical staffing crisis, that his country's public health system was virtually collapsing because it was losing not just many of its doctors, but its best ones.

"I have at least nine hospitals that have no doctor at all, and 20 hospitals with only one doctor looking after a whole district of 80,000 to 120,000 people," Dr. Akosa said. Women in obstructed labor all too often suffer terrible complications or death for lack of an obstetrician, he said.

The study found that Ghana, with only 6 doctors for each 100,000 people, has lost 3 of every 10 doctors it has educated to the United States, Britain, Canada and Australia, each of which has more than 220 doctors per 100,000 people.

Dr. Fitzhugh Mullan, a professor of medicine and public health at George Washington University, who carried out the study, tapped into databases in the four rich countries to learn where their international medical graduates had come from.

He said the flight of doctors was less the result of deliberate policies in the wealthy countries than of their failure to train enough doctors to fill their own needs. For example, the United States has about 17,000 medical school graduates each year for 22,000 first-year residency slots.

"One of the most important things the United States can do for global health, frankly, is to educate more physicians in the United States to work in the United States," he said.

The biggest losers are the small to medium-size countries of Africa and the Caribbean. Dr. Mullan's research found that Jamaica, for example, has lost 41 percent of its doctors and Haiti 35 percent, while Ghana has lost 30 percent and South Africa, Ethiopia and Uganda 14 to 19 percent.

In an editorial that accompanies Dr. Mullan's article, Dr. Lincoln C. Chen, director of the Global Equity Center at Harvard, and Dr. Jo Ivey Boufford, a professor of health policy at New York University, call the exodus of publicly trained doctors "a silent theft" by the richest countries from the poorest.

Crumbling public health systems in poor countries, they wrote, also threaten the health of Americans in the face of potential outbreaks of avian flu and SARS. "Protecting Americans requires viral detection and interdiction at points of origin," they wrote.

Public health leaders in Africa say they will have to reform their own ailing systems. Dr. Francis Omaswa, who was director general of Uganda's health service until July, said that half of its doctor positions were vacant - and that the exodus was not the only cause. For example, he said, some unemployed doctors cannot find jobs because they are not adequately advertised.

Dr. Omaswa, now a special adviser to the World Health Organization on human resources for health, is helping to devise a set of proposals for what African and developed countries can do to ease the staffing crisis. "Africa cannot solve it alone," he said.

Miklos · Oct 28, 2005

Well, as usual, the press misses the point.

The fundamental reason behind the brain drain is the lack of opportunity provided to highly educated people by developing countries. Period.

NYT piece said:
The biggest losers are the small to medium-size countries of Africa and the Caribbean. Dr. Mullan's research found that Jamaica, for example, has lost 41 percent of its doctors and Haiti 35 percent, while Ghana has lost 30 percent and South Africa, Ethiopia and Uganda 14 to 19 percent.

In an editorial that accompanies Dr. Mullan's article, Dr. Lincoln C. Chen, director of the Global Equity Center at Harvard, and Dr. Jo Ivey Boufford, a professor of health policy at New York University, call the exodus of publicly trained doctors "a silent theft" by the richest countries from the poorest.

This is utter non-sense.

A very significant portion of foreign national IMGs do their residencies on J-1 visas. One of the requirements of the J-1 visa is to return to the home country of residence for 2 years after finishing their residency.

(NB: In addition, physicians entering on a J-1 cannot obtain a greencard unless they either obtain a waiver or complete the 2 year requirement. Please note that nothing comparable exists in Europe, the other brain drain beneficiary -- once a foreign physician obtains the residency permit, they need not go back to their home country.)

In other words, the U.S. trains foreign physicians and pushes them out of the U.S. to their home country for two years before they could possibly return. Yet, many do.

Why?

Because they don't have adequate opportunities at home. Perhaps, if those developing governments weren't run by kleptocrats (who have no trouble sending their own relatives to places like London, Paris and Rochester, MN for their healthcare needs) some money would be left over for compensating their own physicians.

Of course, it is far easier for the "Global Equity Center" folk to blame the U.S. for "stealing" foreign physicians.

lilycat · Oct 28, 2005

Couldn't agree more Miklos -- this article frustrated me so much when I read it yesterday -- I have about 2 or 3 draft letters to the NYT that I haven't been able to finish due to irritation. Not to mention the "cross-pollination" effect of training in countries that are generally agreed upon to be on the cutting edge of medical practice and knowledge, and then returning with that knowledge for at least the minimum 2 years. And of course the throwaway sentence about the poor organization of the developing countries' health care systems was buried in the middle of the article (doctors not even being able to find jobs because they aren't posted).

Miklos · Oct 28, 2005

The NEJM free article can be found here.

DrBowtie · Oct 28, 2005

Is it 22,000 PGY-1 only?
How many PGY-2 spots are there?

skypilot · Oct 28, 2005

BrettBatchelor said:
Is it 22,000 PGY-1 only?
How many PGY-2 spots are there?

http://www.nrmp.org/res_match/tables/table1_05.pdf

24,012 positions in the 2005 match per the table.

In 2005:

19,760 PGY1 positions were filled

72 Filled by Canadians
3087 Filled by Non U.S foreign medical graduates
1203 Filled by US residents from foreign med schools and 5th pathway

4362 Total Non U.S. medical

So 22% of all the new interns in the U.S. in 2005 are Foreign medical graduates!

I agree that the problem is far more complicated than the U.S. stealing physicians from the rest of the world.

But 22% of our new interns are foreign grads! We should be training and supplying physicians to the rest of the world. What is the answer to this problem other than turning around the economies of the poor countries so they can offer opportunities for docs? Is a poor country doomed to have no doctors just because it is poor?

Miklos · Oct 28, 2005

skypilot said:
But 22% of our new interns are foreign grads! We should be training and supplying physicians to the rest of the world.

By virtue of the J-1, many of the 3087 foreign national IMGs (actually more, as many get spots outside the match, but I don't have the time at the moment to search for the relevant article) GET PRECISELY THAT OPPORTUNITY.

skypilot said:
What is the answer to this problem other than turning around the economies of the poor countries so they can offer opportunities for docs? Is a poor country doomed to have no doctors just because it is poor?

No. However, poverty is not the primary problem.

Governance is.

Until that gets solved, IMO, one can throw any amount of money at developing countries with few or little results. If you don't believe me, look up the statistics. Many sub-Saharan African countries are worse off today then just after they obtained their independence from their colonial masters. This despite uncounted billions of dollars in aid (much of which ended up in Switzerland and other places where they don't ask too many questions about where you got your loot).

Casey James · Oct 28, 2005

skypilot said:
1203 Filled by US residents from foreign med schools and 5th pathway

What's the "5th pathway"?

Miklos · Oct 28, 2005

Casey James said:
What's the "5th pathway"?

http://www.ama-assn.org/ama/pub/category/9306.html

Casey James · Oct 28, 2005

Miklos said:
http://www.ama-assn.org/ama/pub/category/9306.html

Thanks

Dr. J? · Oct 29, 2005

Miklos said:
Well, as usual, the press misses the point.

The fundamental reason behind the brain drain is the lack of opportunity provided to highly educated people by developing countries. Period.

This is utter non-sense.

A very significant portion of foreign national IMGs do their residencies on J-1 visas. One of the requirements of the J-1 visa is to return to the home country of residence for 2 years after finishing their residency.

(NB: In addition, physicians entering on a J-1 cannot obtain a greencard unless they either obtain a waiver or complete the 2 year requirement. Please note that nothing comparable exists in Europe, the other brain drain beneficiary -- once a foreign physician obtains the residency permit, they need not go back to their home country.)

In other words, the U.S. trains foreign physicians and pushes them out of the U.S. to their home country for two years before they could possibly return. Yet, many do.

Why?

Because they don't have adequate opportunities at home. Perhaps, if those developing governments weren't run by kleptocrats (who have no trouble sending their own relatives to places like London, Paris and Rochester, MN for their healthcare needs) some money would be left over for compensating their own physicians.

Of course, it is far easier for the "Global Equity Center" folk to blame the U.S. for "stealing" foreign physicians.

Quality post, Miklos...you're absolutely spot-on. Keep up the strong work!

Blake · Oct 29, 2005

It's quite rare to meet someone with a clue when it comes to international affairs. Miklos, you're the man

firetown · Nov 1, 2005

Miklos said:
Well, as usual, the press misses the point.

The fundamental reason behind the brain drain is the lack of opportunity provided to highly educated people by developing countries. Period.

This is utter non-sense.

A very significant portion of foreign national IMGs do their residencies on J-1 visas. One of the requirements of the J-1 visa is to return to the home country of residence for 2 years after finishing their residency.

(NB: In addition, physicians entering on a J-1 cannot obtain a greencard unless they either obtain a waiver or complete the 2 year requirement. Please note that nothing comparable exists in Europe, the other brain drain beneficiary -- once a foreign physician obtains the residency permit, they need not go back to their home country.)

In other words, the U.S. trains foreign physicians and pushes them out of the U.S. to their home country for two years before they could possibly return. Yet, many do.

Why?

Because they don't have adequate opportunities at home. Perhaps, if those developing governments weren't run by kleptocrats (who have no trouble sending their own relatives to places like London, Paris and Rochester, MN for their healthcare needs) some money would be left over for compensating their own physicians.

Of course, it is far easier for the "Global Equity Center" folk to blame the U.S. for "stealing" foreign physicians.

I do not think that the press really missed the point. Lack of opportunity is only one of the reasons. While it may be that the J1 limits one to leave the US after training for two years, it does not usually happen. At least I know a good number of doctors from Ghana who got the J1 but somehow have been able to stay on in the US after their training. I am yet to hear of a doctor from Ghana who made it to the US with a J1 visa and finished his training and have gone back to Ghana. It does not happen these days. I know of a number of doctors from nigeria who had the J1 visa in the US and moved to Canada after their training.

The UK is the first point of migration for doctors from Ghana followed by the US. Read this article-almost 70% of doctors produced in Ghana between 1985 and 1994 are in the UK/US. I do not think any of them ever returned to Ghana after their training.
http://www.who.int/hrh/en/HRDJ_3_1_03.pdf

This article shows that compensation alone is not the factor for developing countries to retain doctors. Even if corruption goes to a minimum, there is no way that developing countries will be able to compensate their doctors to the level that developed countries do. To reduce this migration of doctors, developed countries especially UK/US need to put in place policies to stop recruiting doctors from developing countries.

orientedtoself · Nov 1, 2005

firetown said:
This article shows that compensation alone is not the factor for developing countries to retain doctors. Even if corruption goes to a minimum, there is no way that developing countries will be able to compensate their doctors to the level that developed countries do. To reduce this migration of doctors, developed countries especially UK/US need to put in place policies to stop recruiting doctors from developing countries.

I think the problem is that doctors don't want to return to developing countries, not that we are recruiting too aggressively.

medlaw06 · Nov 1, 2005

hey all...don't mean to offend anyone, but own MOTHER is an FMG, so I DO understand the issues behind this. HOWEVER, there is NO WAY you can tell me with a straight face that the US is trying to "recruit" physicians from other countries...this is total BS!!!

The thing is is that the "best" physicians from all these countries WANT to come over to the US because "our streets are paved w/ gold" and any other things that they may have heard about the US in their respective country. My parents came to this country because of the opportunities that this country had...the US did not try to "recruit" them....

Maybe I'm missin' the point here from the other posts, but people from other countries wanna come here to escape the poverty/propaganda/politics/persecution in their countries....or maybe they wanna rack up the $$$$ for the currency exchange....or whatever the deal is, BUT IT'S NOT BECAUSE THE US IS RECRUITING THEM!! This is rediculous!!

You can go ahead and flame me if you want, but when you close your eyes at night and rest your head on the pillow, you can't say that I am lying!! :laugh:

skypilot · Nov 1, 2005

medlaw06 said:
The thing is is that the "best" physicians from all these countries WANT to come over to the US because "our streets are paved w/ gold" and any other things that they may have heard about the US in their respective country. My parents came to this country because of the opportunities that this country had...the US did not try to "recruit" them....

Maybe I'm missin' the point here from the other posts, but people from other countries wanna come here to escape the poverty/propaganda/politics/persecution in their countries....or maybe they wanna rack up the $$$$ for the currency exchange....or whatever the deal is, BUT IT'S NOT BECAUSE THE US IS RECRUITING THEM!! This is ridiculous!!
:

Not recruiting them? Almost a quarter of the residency spots are reserved for them. I guess the question is if these residency spots weren't available would they stay in their home countries and work as docs. Probably not. They would still move here and find other jobs.

firetown · Nov 1, 2005

skypilot said:
Not recruiting them? Almost a quarter of the residency spots are reserved for them. I guess the question is if these residency spots weren't available would they stay in their home countries and work as docs. Probably not. They would still move here and find other jobs.

I agree with you. You don't need to put up recruitment posters posters in other countries for people to realise that you are actively recruiting. Recruitment comes in so many forms and shapes, directly and indirectly.
I know that the US actively recruits from Canada who in turn actively recruits from South Africa. There are loads of african doctors in South Africa that has been recuited from the west coast of Africa - all developing countries. This is just one example of how the recruitment works. In which ever way you may look at it the NET EFFECT is that the US, UK, Australia and Canada have a shortage of physicians that are filled with physicians recruited directly or indirectly from developing countries.

People might still move if there are reduced residency positions for other jobs but could be at a reduced rate. But reduced residency spots will be a bad policy as that will create more physician shortages. It is a complex myriad of issues that I do not see being solved anytime soon.

Annette · Nov 1, 2005

Residency spots are not reserved for anyone! There are more residency spots than there are US medical students. FMG's take the rest. The US could solve all this with opening up enrollment for more US students. (It would also limit the number of people having to go to off-shore schools.)

skypilot · Nov 1, 2005

Annette said:
Residency spots are not reserved for anyone! There are more residency spots than there are US medical students. FMG's take the rest. The US could solve all this with opening up enrollment for more US students. (It would also limit the number of people having to go to off-shore schools.)

We know exactly how many medical students are going to graduate each year. The number of residency spots is regulated. Who do you think all those residency spots are for? And do you think immigrant physicians return home after completing their training in the U.S?

f_w · Nov 1, 2005

The 'US' indeed doesn't recruit physicians overseas. The relative openness of the US medical system to FMGs and the high quality training programs are enough of a draw to make us come. The relative lack of hierachies after completion of residency and the fairly decent economic circumstances are an additional reason to stay after residency (no, the roads are not paved with gold in US medicine. But if you work hard, you have more opportunities than in most other places).

Other countries (typically the ones with goverment sponsored healthcare systems) openly recruit physicians abroad (e.g. AU, NZ, Canada, UK). Officially, they don't recruit in 3rd world countries, but in reality this is where the majority of their supply comes from.

Miklos · Nov 2, 2005

firetown said:
I do not think that the press really missed the point. Lack of opportunity is only one of the reasons. While it may be that the J1 limits one to leave the US after training for two years, it does not usually happen. At least I know a good number of doctors from Ghana who got the J1 but somehow have been able to stay on in the US after their training. I am yet to hear of a doctor from Ghana who made it to the US with a J1 visa and finished his training and have gone back to Ghana. It does not happen these days.

Though obtaining a J-1 waiver is possible (depending on your country of origin), it is not that easy.

firetown said:
I know of a number of doctors from nigeria who had the J1 visa in the US and moved to Canada after their training.

Thanks for supporting my argument. Why is it again that the Nigerians move the Canada after completing their residency in the U.S.? I'd bet a serious amount of money that it has to do with a lack of opportunity (this time in the U.S.)

firetown said:
The UK is the first point of migration for doctors from Ghana followed by the US. Read this article-almost 70% of doctors produced in Ghana between 1985 and 1994 are in the UK/US. I do not think any of them ever returned to Ghana after their training.
http://www.who.int/hrh/en/HRDJ_3_1_03.pdf

Please note the political situation in Ghana between 1981 and 1992 was in, uhmm.. "flux".

That would help contribute to a lack of opportunity, wouldn't it?

firetown said:
This article shows that compensation alone is not the factor for developing countries to retain doctors. Even if corruption goes to a minimum, there is no way that developing countries will be able to compensate their doctors to the level that developed countries do.

Re: corruption. According to TIs CPI, Ghana is ranked 65th overall or 7th in the region. I'd say that there's room for improvement.

In addition, if we are discussing compensation in terms of PPP, I disagree.

(What the West could do is to address some of the problems of underdevelopment is to eliminate tariffs on agricultural products and stop subsidies to Western farmers. The answer to underdevelopment lies in trade, not aid. Don't believe me? See the rise of certain Asian nations over the last couple of decades, especially when compared to Africa.)

firetown said:
To reduce this migration of doctors, developed countries especially UK/US need to put in place policies to stop recruiting doctors from developing countries.

As f_w points out above, the US does not recruit physicians (other countries in one way or another do).

However, you're pretty comfortable denying individual human rights to these physicians, right? To me it sounds like protectionism in the guise of "helping others."

Come to think of it, there is a country with the worst of both worlds for IMGs.

On the basis of their education, they are actively recruited to settle the country, given visas, etc... However, when it comes to recognizing their education and allowing them to practice medicine, they are often met by insurmountable barriers (e.g. not enough residency spots, etc..)

So, they end up driving cabs and delivering pizzas. IMO, a waste of human potential.

The place?

Canada.

Miklos · Nov 2, 2005

skypilot said:
Not recruiting them? Almost a quarter of the residency spots are reserved for them. I guess the question is if these residency spots weren't available would they stay in their home countries and work as docs. Probably not. They would still move here and find other jobs.

See my Canada argument above. One of the greatest things about the US is that it allows these foreigners to reach their potential and benefit the society as a whole. Of course, you'd need to understand classic liberal economics to understand this.

Second, the spots are not "reserved" for them.

Legislation caps the total number of residency positions at close to 100,000 per year. U.S. allopathic med schools in order to protect the economic interests of their graduates have purposely limited their number for a fairly long time now.

Some of the consequences of this shortage (the invisible hand of the marketplace in action):

Osteopathic schools have mushroomed to take advantage of this.
Assorted mid-levels are replacing physicians in all kinds of fields.

The role of IMGs is a little like that of Mexicans in the U.S. economy overall. They fill a need that the locals don't or can't.

Dr. J? · Nov 2, 2005

Miklos - Nice invocation of Adam Smith's 'invisible hand'.

IMG's are simply 'voting with their feet' when it comes to where they choose to ultimately train, settle and practice. I think Medlaw06's comments pretty much sum up why this country trains so many IMG's - one word "OPPORTUNITY". Of course, OPPORTUNITY occurs anywhere in the globe where there is a free-market and a freely elected government.

CircleTheDrain · Nov 2, 2005

Miklos said:
Though obtaining a J-1 waiver is possible (depending on your country of origin), it is not that easy.

Thanks for supporting my argument. Why is it again that the Nigerians move the Canada after completing their residency in the U.S.? I'd bet a serious amount of money that it has to do with a lack of opportunity (this time in the U.S.)

Please note the political situation in Ghana between 1981 and 1992 was in, uhmm.. "flux".

That would help contribute to a lack of opportunity, wouldn't it?

Re: corruption. According to TIs CPI, Ghana is ranked 65th overall or 7th in the region. I'd say that there's room for improvement.

In addition, if we are discussing compensation in terms of PPP, I disagree.

(What the West could do is to address some of the problems of underdevelopment is to eliminate tariffs on agricultural products and stop subsidies to Western farmers. The answer to underdevelopment lies in trade, not aid. Don't believe me? See the rise of certain Asian nations over the last couple of decades, especially when compared to Africa.)

As f_w points out above, the US does not recruit physicians (other countries in one way or another do).

However, you're pretty comfortable denying individual human rights to these physicians, right? To me it sounds like protectionism in the guise of "helping others."

Come to think of it, there is a country with the worst of both worlds for IMGs.

On the basis of their education, they are actively recruited to settle the country, given visas, etc... However, when it comes to recognizing their education and allowing them to practice medicine, they are often met by insurmountable barriers (e.g. not enough residency spots, etc..)

So, they end up driving cabs and delivering pizzas. IMO, a waste of human potential.

The place?

Canada.

This is inaccurate and misleading. Canada no more recruits foreign doctors than the US does. The immigration setup gives applicants points for speaking English or French, as well as education, financial stability, plus many other areas. Its not suprising that doctors score high in this point system. However Canada sets higher standards for FMGs and thus is much more restrictive in letting FMG practise then the US.

Pilot Doc · Nov 2, 2005

skypilot said:
the question is if these residency spots weren't available would they stay in their home countries and work as docs. Probably not. They would still move here and find other jobs.

Are you familiar with the general nature of US immigration policy? If so, it should be clear that the answer to your question is an unqualified yes. FMG's move to the US because, as docs, they can obtain a legal right to work. If they did not come as docs, they would have to compete for a very limited supply of green cards or come illegally to find whatever work was available. The former case would substantially curtail a 3rd world brain drain; the latter would substantially shift the calculus of whether living in the US or the home country would produce a better life.

NR117 · Nov 2, 2005

CircleTheDrain said:
This is inaccurate and misleading. Canada no more recruits foreign doctors than the US does. The immigration setup gives applicants points for speaking English or French, as well as education, financial stability, plus many other areas. Its not suprising that doctors score high in this point system. However Canada sets higher standards for FMGs and thus is much more restrictive in letting FMG practise then the US.

I beg to differ. Miklos makes some very good points. What is misleading is the Canadian consulates and embassies abroad NOT being forthcoming with IMG's about their chances (or lack of it thereof) of getting licensed in Canada. You'd be surprised how many IMG's have been definitely misled into believing that all they had to do was take the LMCC exams, which is no big deal. So they resign from their jobs, move their families over and THEN realize how bad things really look for them. Keep in mind that there must also be some physicians who would still come to Canada knowingly, willing to work in a different field, just to be able to leave their corrupt native country behind.

And it isn't about having higher standards for IMG's either. Far from it. IMG's are never on a level playing field with Canadian graduates. Even those IMG's whose scores on the LMCC exams are literally off the chart, meaning that they scored higher than 90% of Canadian graduates are not given exemption from repeating their internship and their residency. I know this for a fact.

Having said all that, the physician shortage in Canada has reached such levels that most provinces have been forced to issue resricted licenses to IMG's in certain fields, with the provision that they will work in an underserviced area for a certain number of years. Suffice it to say that things are in flux right now and who knows what kinds of policy changes await the IMG's in Canada...

NR117 · Nov 2, 2005

One more thing: Whether or not IMG's are likely to be able to practice have a LOT to do with politics and much less to do with standards. Case in point: There were a few IMG's I met when they worked as observers at the hospital I was doing one of my rotations. Even though they didn't do that great on their LMCC's (they were talking about it, that's how I know), one of them ended up going to Eastern Canada(?Nova Scotia) on some kind of restricted license because there's a big shortage of GP's there. He will be able to take the Canadian Boards in Family Medicine after a certain number of years.
Now contrast this with an excellent IMG I met, who was a subspecialist. He'd been I think an assistant or associate professor in his home country, with numerous publications on his CV and last time I saw him, things still didn't look good for him. Why? Because his field is VERY competitive to get into, and there's no way (shortage or not) he will even be eligible to APPLY for a residency, let alone get licensed in Canada.

So it's mostly politics, as I said...When politicians need to tell their constituents "Here, we're trying to solve the GP shortage in this province.", then IMG's get licenses. Otherwise they usually end up trying to go to the US.

skypilot · Nov 2, 2005

Pilot Doc said:
Are you familiar with the general nature of US immigration policy? If so, it should be clear that the answer to your question is an unqualified yes. FMG's move to the US because, as docs, they can obtain a legal right to work. If they did not come as docs, they would have to compete for a very limited supply of green cards or come illegally to find whatever work was available. The former case would substantially curtail a 3rd world brain drain; the latter would substantially shift the calculus of whether living in the US or the home country would produce a better life.

So do you advocate closing this doorway to the U.S. and increasing the number of U.S. medical school spots? Would we be doing this to benefit the third world countries which supply our labor? Or would their be more self interest involved?

f_w · Nov 2, 2005

Are you familiar with the general nature of US immigration policy? If so, it should be clear that the answer to your question is an unqualified yes. FMG's move to the US because, as docs, they can obtain a legal right to work. If they did not come as docs, they would have to compete for a very limited supply of green cards or come illegally to find whatever work was available.

I am not sure whether you are familiar with US immigration policy. As a matter of fact, there are additional hurdles to immigration specifically for physicians. It is far easier to immigrate to the US as 'specialty cook chinese' than as a physician (the system is so f)###^ up that I know docs who immigrated as 'medical assistants' 'lab techs' and other lower level job descriptions).

Physicians come here for the same reasons as engineers, IT folk and accountants. The draw of the US is not limited to emigrees from corrupt third world dictatorships. There are plenty of FMGs from countries which are politically stable and economically developed.

Bottom line, it is an individual decision. The US doesn't actively recruit physicians overseas. In order to get here, you have to invest lots of time and money. As long as there is an opportunity to work here, professionals will come.

f_w · Nov 2, 2005

By the way:

Every year, about 4000 physicians in training enter the US on a new J1 exchange visitor visa. This visa requires them to return to their home country for two years after completion of residency/fellowship before they are eligible to re-enter on any sort of work visa or a green-card. However, the department of state every year grants about 1200 waivers from this requirement to physicians either serving in health care personnel shortage areas (approx 1/3 of the US) or veterans administration facilities. So, the majority of the J1 physicians at least initially returns to their home country (some will come back after 2 years, these numbers are not tracked).

firetown · Nov 2, 2005

Miklos said:
Though obtaining a J-1 waiver is possible (depending on your country of origin), it is not that easy.

Thanks for supporting my argument. Why is it again that the Nigerians move the Canada after completing their residency in the U.S.? I'd bet a serious amount of money that it has to do with a lack of opportunity (this time in the U.S.)

Not supporting your argument. The point that you made was that J1 requires physicians to return to their home country after training. Moving to Canada is not returning to Nigeria.

Miklos said:
Please note the political situation in Ghana between 1981 and 1992 was in, uhmm.. "flux".

That would help contribute to a lack of opportunity, wouldn't it?

Maybe, but what do you really mean by lack of opportunity. Is it lack of training opportunities or lack of places to practice. There are never lack of places to practice.

Miklos said:
Re: corruption. According to TIs CPI, Ghana is ranked 65th overall or 7th in the region. I'd say that there's room for improvement.

In addition, if we are discussing compensation in terms of PPP, I disagree.

Even in terms of PPP, physicians in developed countries are much much better compensated than those in developing countries. Why do you think that people still leave?

Miklos said:
(What the West could do is to address some of the problems of underdevelopment is to eliminate tariffs on agricultural products and stop subsidies to Western farmers. The answer to underdevelopment lies in trade, not aid. Don't believe me? See the rise of certain Asian nations over the last couple of decades, especially when compared to Africa.)

Agreed, could be one of the ways of creating wealth in developing countries.

Miklos said:
As f_w points out above, the US does not recruit physicians (other countries in one way or another do).

However, you're pretty comfortable denying individual human rights to these physicians, right? To me it sounds like protectionism in the guise of "helping others."

Really, denying individual human rights. After spending so much on the education of physicians, what is wrong with asking them to give back to the community that supported them. Have you heard of return of service agreements that happens in Canada and the US. These agreements must certainly be denying some individual human rights?

Pilot Doc · Nov 2, 2005

skypilot said:
So do you advocate closing this doorway to the U.S. and increasing the number of U.S. medical school spots? Would we be doing this to benefit the third world countries which supply our labor? Or would their be more self interest involved?

I'm not sure I understand your response, but in any event I'm not advocating anything. I'm just critiquing the logic in your original post.

You say even if we banned IMG's from GME the same number of physicians would immigrate. i.e. The docs who immigrate to the US do so almost solely without reference to their employment prospects. They would be just as happy working for the Mass Turnpike as Mass General. The availability of physician jobs has no significant effect on physician immigration to the united states.

That's just not credible. For all the hurdles of a J-1 Visa, it gives a good chance at US citizenship and having a $100K plus job for life. (Not to mention a resaonable job during residency) Simple supply and demand - $100K jobs attract more people that $20K jobs. A significant number of docs would stay docs at home if they couldn't be a doc in America.

Pilot Doc · Nov 2, 2005

f_w said:
As long as there is an opportunity to work here, professionals will come.

I agree. My post was a counter to the statment that opportunity to work as a doc was not a substantial driver of physician immigration. If IMG's didnt' have access to GME, many fewer would immigrate.

And even if only 1/3 of J1 visa holders get to stay, those odds probably look pretty attractive to prospective immigrants, especially considering that the denominator is less that 100% (i.e. some J1's want to go home.)

NR117 · Nov 2, 2005

firetown said:
Really, denying individual human rights. After spending so much on the education of physicians, what is wrong with asking them to give back to the community that supported them. Have you heard of return of service agreements that happens in Canada and the US. These agreements must certainly be denying some individual human rights?

Firetown, it's interesting that you think it's OK for engineers, pharmacists, nurses and God knows who else to leave their country but when it comes to doctors, no, they have to give back to the community that supported them. What if that very community is preventing them from doing the type of work that they are passionate about, say, research? What if the infrastructure is not there? They should just languish where they belong, right?

What if they have already done compulsory service in some underserviced area in their home country? How long should it take to pay their debt? A lifetime?

People who enter those return of service agreements you talk about have clearly weighed their options and made a CHOICE to enter them. What you are suggesting amounts to taking people's choices away. No comparison there. For you to portray this as something that is in the best interest of those foreign countries, oh puhleaeeeeze.

You're not fooling anyone.

f_w · Nov 3, 2005

After spending so much on the education of physicians, what is wrong with asking them to give back to the community that supported them.

I enjoyed the benefits of a 'free' medical education because my parents paid for it with decades worth of high taxation. It is paid for, I have no bad conscience whatsoever about not returning at this time. (It's not even about the money. I could make a good living in my field, it is the lack of opportunities. Funny enough, the physician emigration from my home country has finally depleted the supply. With shortages starting to crop up, the goverment was forced to address some of the junior doctors grievances. Maybe, a couple of years from now, the conditions will be favourable for a return, but right now I am better off in the states.)

Have you heard of return of service agreements that happens in Canada and the US. These agreements must certainly be denying some individual human rights?

Agreement being the key word here. If a country decides to offer people a deal along the lines of: we send you to medschool but you have to work for the goverment health service for 5 years after you graduate, that would be ok. Just like people in the US make a deal with the military to get a free medschool education in exchange for a service committment (HPSP), this would be two parties entering into some sort of contract. No human rights violated here.

What you are advocating is making the US the enforcer of other countries education and health policies. That would be a novel idea.

DiaHuq · Nov 3, 2005

it's not just opportunities, it's also the money, it's not making 100k+, it's making enough to support your family and giving your kids better opportunities. I grew up here so I had no idea how bad it was back home, my cousin is a doctor and gets paid, about 150$ a month, the people who make the money are those in the government, he doesn't make enough to pay for an apartment and food at the same time, so his wife lives with his parents. I think any one of you if you were in similar circumstances would choose to immigrate to a country with opportunities, like everyone in america had some point in their family tree did.

you have to understand, the son of the person in power has 10 cars, all are bmws, benz, hummer and stuffl like that.

Miklos · Nov 3, 2005

A couple of your points have been rebutted above by NR117 and f_w, so I'll just cover the ones that weren't.

firetown said:
Not supporting your argument. The point that you made was that J1 requires physicians to return to their home country after training. Moving to Canada is not returning to Nigeria.

If they had Canadian citizenship at the time of their J-1 application and designated it, that fulfills the requirement. In other words, they had already immigrated to Canada.

(Interestingly, this is a great way to get around Canada's anti-IMG policies, as it is far easier to have your U.S. residency recognized than applying for a Canadian one as an IMG. At a minimum, they'll be able to get restricted -- by that I mean hospital only -- licenses in underserved areas.)

From the ECFMG's website:

Two-Year Home Country Physical Presence Requirement
In accordance with Section 212(e) of the Immigration and Nationality Act, as amended, all J-1 Exchange Visitors who are sponsored by ECFMG for the purpose of graduate medical education or training (and all accompanying J-2 dependents) are automatically obligated to return to their country of most recent legal permanent residence for an aggregate of at least two years. At the initiation of J-1 sponsorship, the J-1 applicant declares his country of most recent legal permanent residence and submits the corresponding Statement of Need, thereby committing to return to that country. The 212(e) obligation may not be fulfilled in a different country. An individual must fulfill (or obtain a waiver of) this obligation before being eligible for a change or adjustment of visa status to certain types of U.S. visas. These visa types include: H (temporary worker), L (intra-company transferee), and U.S. permanent resident.

firetown said:
Maybe, but what do you really mean by lack of opportunity. Is it lack of training opportunities or lack of places to practice. There are never lack of places to practice.

I think that lack of opportunity speaks for itself. Unless of course, you expect them to work for free in a politically unstable country.

Perhaps, you can lead the way?

firetown said:
Even in terms of PPP, physicians in developed countries are much much better compensated than those in developing countries. Why do you think that people still leave?

No doubt. However, you were suggesting that they need to be compensated equally at direct exchange rates in order to compete for their services. As I pointed out, using PPP, this is not the case.

firetown · Nov 3, 2005

NR117 said:
Firetown, it's interesting that you think it's OK for engineers, pharmacists, nurses and God knows who else to leave their country but when it comes to doctors, no, they have to give back to the community that supported them. What if that very community is preventing them from doing the type of work that they are passionate about, say, research? What if the infrastructure is not there? They should just languish where they belong, right?

What if they have already done compulsory service in some underserviced area in their home country? How long should it take to pay their debt? A lifetime?

People who enter those return of service agreements you talk about have clearly weighed their options and made a CHOICE to enter them. What you are suggesting amounts to taking people's choices away. No comparison there. For you to portray this as something that is in the best interest of those foreign countries, oh puhleaeeeeze. You're not fooling anyone.

What I wrote goes for every profession. I limit it to physicians here since this is a physician forum. Recruitment is worse for nurses, I have seen adverts from the US in developing countries for recruitment. You will be intereted to know that physicains leave right after medical school with no service in any underservice area.

I don't know what you mean by taking people choices away. All that I wrote was that I do not see anything wrong with communities asking for return of service from physicians. That is certainly not denying them their human rights.

firetown · Nov 3, 2005

f_w said:
After spending so much on the education of physicians, what is wrong with asking them to give back to the community that supported them.

I enjoyed the benefits of a 'free' medical education because my parents paid for it with decades worth of high taxation. It is paid for, I have no bad conscience whatsoever about not returning at this time. (It's not even about the money. I could make a good living in my field, it is the lack of opportunities. Funny enough, the physician emigration from my home country has finally depleted the supply. With shortages starting to crop up, the goverment was forced to address some of the junior doctors grievances. Maybe, a couple of years from now, the conditions will be favourable for a return, but right now I am better off in the states.)

Have you heard of return of service agreements that happens in Canada and the US. These agreements must certainly be denying some individual human rights?

Agreement being the key word here. If a country decides to offer people a deal along the lines of: we send you to medschool but you have to work for the goverment health service for 5 years after you graduate, that would be ok. Just like people in the US make a deal with the military to get a free medschool education in exchange for a service committment (HPSP), this would be two parties entering into some sort of contract. No human rights violated here.

What you are advocating is making the US the enforcer of other countries education and health policies. That would be a novel idea.

It is not a question of having a bad conscience or not. It is having something being done to help with help services delivery in developing countries. If somebody wants to be patriotic and go back that is left to individual decisions as opportunities as being suggested in this thread will still be lacking. And as you said maybe when conditions improve people might go back.

The US certainly cannot be the enforcer of other countries policies. Can the US help in any way to reduce the rate? I think so in conjunction with the developing countries. Will the US be willing to help, maybe a ys in theory but a no in practice.

firetown · Nov 3, 2005

If they had Canadian citizenship at the time of their J-1 application and designated it, that fulfills the requirement. In other words, they had already immigrated to Canada.

No these people only got a work permit from Canada. To be a Canadian citizen, these people will have to have to apply to be landed immigrants and leave in Canada for three years before they become citizens. But that is only a small number that move out of the US. The majority stay on after their traing even with J1 visa's.

No doubt. However, you were suggesting that they need to be compensated equally at direct exchange rates in order to compete for their services. As I pointed out, using PPP, this is not the case.

Read the previous post by DiaHuq. It is making enough to support your family and give your kids better opportunities. This does not mean being compensated equally at direct exchange rates. DiaHuq made the point that physicians in his home country make about $150 a month. This I think is a fair approximation of what most doctors would make in developing countries. Having some experience of living in some developing countries, this amount will certainly not give you a comparable purchasing power with a physician in the US. I can't think of any developing country that will have comparable compensation to how muh physicians earn in the US even with PPP.

Miklos · Nov 3, 2005

firetown said:
No these people only got a work permit from Canada. To be a Canadian citizen, these people will have to have to apply to be landed immigrants and leave in Canada for three years before they become citizens.

So, they chose to go to Canada. As they presumably did their residency on a J-1, they cannot return to the U.S. unless they get a waiver.

See http://travel.state.gov/visa/temp/info/info_1294.html

Dep. of State said:
Questions Concerning Permanent Residents of Canada

Q. I came to the U.S. from a country other than Canada on a J-1 visa, and after completion of my J program I moved to Canada and acquired landed immigrant status in Canada

A. Which country am I subject to return to for my two-year residence requirement -- my former country of residence or my current one, Canada?

A. You are subject to return to your former country of residence. J-1 regulations stipulate that an exchange visitor is subject to the country of his/her legal permanent residence at the time that the visitor acquires the J-1 status. The visitor must return to his/her former country of residence in order to fulfill the two-year home residence requirement or he/she must receive a waiver of the requirement.

firetown said:
But that is only a small number that move out of the US. The majority stay on after their traing even with J1 visa's.

Please cite your source. I don't have time to do the research, so I'll go with f_w's numbers, because I vaguely remember reading the same.

f_w said:
Every year, about 4000 physicians in training enter the US on a new J1 exchange visitor visa. This visa requires them to return to their home country for two years after completion of residency/fellowship before they are eligible to re-enter on any sort of work visa or a green-card. However, the department of state every year grants about 1200 waivers from this requirement to physicians either serving in health care personnel shortage areas (approx 1/3 of the US) or veterans administration facilities. So, the majority of the J1 physicians at least initially returns to their home country (some will come back after 2 years, these numbers are not tracked).

Miklos · Nov 3, 2005

firetown said:
You will be intereted to know that physicains leave right after medical school with no service in any underservice area.

So?

Unless they are obligated to by an agreement into which they voluntarily entered, why should they?

(Are plumbers required to work in an "underserved area" after completion of their vocational training?)

BTW, before coming to the U.S for residency training, foreign physicians are required to produce a statement of need.

ECFMG said:
Provide a Statement of Need from the Ministry of Health of the country of most recent legal permanent residence, regardless of country of citizenship. This statement provides written assurance that the country needs physicians trained in the proposed specialty and/or subspecialty. It also serves to confirm the applicant physician's commitment to return to that country upon completion of training in the United States, as required by Section 212(e) of the Immigration and Nationality Act, as amended.

firetown said:
I don't know what you mean by taking people choices away. All that I wrote was that I do not see anything wrong with communities asking for return of service from physicians. That is certainly not denying them their human rights.

Oh, ok..now, it is "asking for a return in service."

Precisely what form would that request take?

MacGyver · Nov 4, 2005

Please there are so many loopholes to stay in teh US its not funny.

Dont talk to me about J1 required to go back to their home country, thats a freaking joke. All they have to do is agree to work in an "underserved" area for a couple of years, and they get a lifetime pass to stay in the USA as long as they want.

The definiition of "underserved" is ridiculous. You are talking about cush suburbs in many cases who have plenty of docs, yet they fall below some arbitrary threshold and get labeled "underserved"

Consider that in Texas, ALL of the suburbs of Dallas and Houston are labeled "underserved" despite the fact that when you take the aggregate metropolitan doctor/population ratio, they actually have a large number of docs.

f_w · Nov 4, 2005

http://www.bcis.com/images/j-current-state.pdf

page CRS8

.....The review also showed that over the four -year period, the Conrad programs had requested a total of 2,949 waivers....

Not exactly a flood.

------

And I don't know where you get the 'lifetime pass to stay in the US' (let me know, I know a couple of folks who would like to pick one up). In order to become a permanent resident, J1 physicians have to either go through the same hoops as any other immigrant, or they have to practice in the underserved location for a total of 5 years.

-----

In order to obtain a J1 visa for the US, a foreign physician has to provide a letter of support from a designated official in his home countries ministry of health. Many countries issue this letter, some don't (e.g. Israel). They are fully aware that a number of the docs going abroad for training will not return. If they were interested to get these people back, it would be up to them to find a contractual arrangement ensuring their return.

-----

Yes, there are ways around the J1 foreign residency requirement. But they all exist because the US goverment wants it that way.

NYT article about IMG's

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