New Tennessee IMG Law

[Wilf]

A friend sent me the news this weekend that Tennessee is becoming the first state ever to allow IMGs to come over and practice without US based residency training.
I am wondering what folks here think about this.
My first thoughts are that this is not a good idea, as the quality of training around the world varies a lot and I doubt the powers that be will have a good way of handling this. Many doctors in the US are already not great and I feel like this will only increase the number of doctors not providing optimal and extremely competent care. Of course the stated reason for this new policy is that we need more doctors in rural areas, but much like midlevels or doctors who were let into medical school here because they were from underserved areas, it does not mean these providers will actually practice in these high need areas.
On the other hand, these physicians are going to be required to pass all three USMLE steps, as I understand it, to be able to practice. These doctors would probably provide better care than the vast majority of NPs/PAs and could probably be paid approximately the same.

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[Celexa]

My understanding from what I read about this is it literally requires them to first work at teaching hospitals for a period in time. In other words it lets the hospitals turn foreign physicians explicitly into indentured servants in direct competition with physicians who are board-certified by american institions, as well as have an additional tool for union busting among the house staff (why negotiate with a resident union when you can pay relative peanuts to foreign physicians who don't even have the paper thin protection of acgme standards?)

It is an unambiguously awful idea.

 

[shoomer]

In addition to the issue with education not being standardized globally, the removal of residency training as a bottleneck will drive down compensation as saturation is a likelihood with a change like this. They have to pass all 3 steps so that's a bit of a barrier right now, but that will change over time. I already know a lot of people who went abroad for medical school and some had difficulty with getting into residency but have Step 1+2 passed, and that was before anything like this was ever even seen as an option.

 

[Sushirolls]

Wrong solution.

A better option would be to eliminate any PGY requirements, and step 3 requirements for independent physician licensure.

Let a medical DO/MD grad free practice as a GP.

Residency/specialties can still be restrictive/selective into their applications, but flood the market with MD/DO GPs and push out the ARNP/PAs.

 

[voxveritatisetlucis]

Wrong solution.

A better option would be to eliminate any PGY requirements, and step 3 requirements for independent physician licensure.

Let a medical DO/MD grad free practice as a GP.

Residency/specialties can still be restrictive/selective into their applications, but flood the market with MD/DO GPs and push out the ARNP/PAs.

Yes but the goal of the law isn’t to expand accessibility or improve quality of care but rather to lower physician salaries and thus increase profits for HCA and other hospitals systems

 

[whopper]

Most countries have a very different system vs to the US so I can see serious problems. E.g. in several countries medical school training involved NO CLINICAL EXPERIENCE or MUCH LESS vs the USA.

So in short IMGs could have far less training and be at the equivalent of an ending 2nd year medstudent. I've noticed IMGs from other countries are usually behind US grads in clinical experience although within several months they often times catch up but this is not without real world bad consequences and it's not just for patients, the IMG's team-members but themselves as well. Residency is already very tough. Adding more obstacles is just going to make it that much more likely one of them could mess up and get kicked out of residency.

The closest country to the USA aside from Canada in terms of culture is the UK. In the UK medical school is different from the USA. Medschool there, less is expected, but residency training there is longer. Like I said a medical school graduate there is more like the equivalent of a 2nd year medstudent.

 

[SmallBird]

Residency is already very tough. Adding more obstacles is just going to make it that much more likely one of them could mess up and get kicked out of residency.

What are you saying here? This law wouldn't require IMGs to do residency. I don't see what your statement has to do with that.

But yes this is a terrible idea and we should organize an HCA boycott.

 

[forchinet121]

What are you saying here? This law wouldn't require IMGs to do residency. I don't see what your statement has to do with that.

But yes this is a terrible idea and we should organize an HCA boycott.

What does HCA have to do with this?

 

[voxveritatisetlucis]

What does HCA have to do with this?

They seek to benefit from flooding the labor supply just like they did with the EM residencies

 

[Stagg737]

They seek to benefit from flooding the labor supply just like they did with the EM residencies

Did they lobby for this law or something? While large systems/companies would benefit I'd be curious to see where this came from and who was backing it.

 

[Celexa]

Did they lobby for this law or something? While large systems/companies would benefit I'd be curious to see where this came from and who was backing it.

Reddit comments are not the most sterling of sources, but the top comments on this thread certainly raise some eyebrows about exactly where this came from:

 

[G Sheb]

Weakening the standards to become a practicing physician, whether by the proliferation of US med schools or laws like these, is likely far more detrimental to the career than anything NPs could do.

 

[voxveritatisetlucis]

going to have a lot of physicians with 400k in debt making 80k per year if this spreads to other states

Where is the ama?

 

[SmallBird]

Did they lobby for this law or something? While large systems/companies would benefit I'd be curious to see where this came from and who was backing it.

I first heard about this a few weeks ago and although I can't find the article it references HCA as being a huge supporter as they no doubt hope to endenture the IMGs in their hospitals.

 

[whopper]

What are you saying here? This law wouldn't require IMGs to do residency. I don't see what your statement has to do with that.

You are correct to point this out.

I get why they'd want to try to scoop some foreign doctors. I've seen some doctors from other countries, even good ones, and they might say be in their 40s or older and don't want to undergo residency all over again.

All that said, however, you simply just can't take someone in without some type of way to make sure they can do the work.

 

[VA Hopeful Dr]

What does HCA have to do with this?

HCA is headquartered in TN. I'd be shocked if they weren't a major driver of this.

Top 10 largest IDNs headquartered in Tennessee

We compiled a list of the top 10 the largest IDNs that are headquartered in Tennessee.

www.definitivehc.com

 

[voxveritatisetlucis]

If this passes in other states, will be very bad for physicians. They should collectively agree to not work at any hospitals who do this

 

[voxveritatisetlucis]

Looks like Carolina is next. Published two days ago.

Lack of physicians and violence in rural hospitals focus of bill in Senate

The North Carolina Senate is considering a bill that would make it easier for military and foreign doctors to practice in NC. It would also provide protections from violence in rural hospitals, among other health-related measures in the bill.

www.carolinajournal.com

Maine:

New bill aims to remove barriers to allow foreign-trained doctors to work in Maine

wgme.com

Massachusetts

Mass. bill would reduce barriers for foreign-trained medical professionals

More than 20 percent of the state's foreign-trained medical professionals are unable to practice

www.heraldnews.com

Alabama:

"Alabama Needs More Doctors": House passes Physician Workforce Act

The bill aims to boost recruitment of out-of-state physicians to Alabama.

www.alreporter.com

Arizona

Arizona needs more doctors | Arizona Capitol Times

Listen to this article Arizona is facing a critical physician shortage. In 2020, nearly 40% of residents lived in communities with healthcare shortages and our state ranks 44th out of 50 in the number of primary care physicians per capita. And this problem will only get worse—in 2030, Arizona is...

azcapitoltimes.com

 

[SmallBird]

This really has the potential to dramatically alter the workforce environment. As an IMG, I'm proud of how hard I had to work to get where I am, and consider my completion of a US Residency to be absolutely central to my ability to practice here effectively. There is a potential for a dramatic influx of foreign trained doctors who are going to be in a serious misalignment in terms of practice style, standards of care, documentation practices, available treatments and medications, and the inclusion of whom will introduce major inconsistencies in care and disrupt the physician labor market in a very negative way.

 

[voxveritatisetlucis]

Guy who supports the bills for Cato and other think tanks apparently owns a large private surgical practice. Another one who has already benefited from the system and now doesn’t care what happens in the future

https://www.cato.org/people/jeffrey-singer

 

[comp1]

I think psychiatry is a bit harder than other specialties to practice in a foreign country. Even going to New Zealand or the UK, I think I would have some issues with the cultural differences, to say nothing of an actual language barrier. That said...this will not ruin the workforce. This will not even depress wages. NPs did not and this will not either. There is so much business, it's just not possible even if we import every psychiatrist from around the world and leave everywhere else bereft. The US already has a quarter of all psychiatrists.

 

[SmallBird]

I think psychiatry is a bit harder than other specialties to practice in a foreign country. Even going to New Zealand or the UK, I think I would have some issues with the cultural differences, to say nothing of an actual language barrier. That said...this will not ruin the workforce. This will not even depress wages. NPs did not and this will not either. There is so much business, it's just not possible even if we import every psychiatrist from around the world and leave everywhere else bereft. The US already has a quarter of all psychiatrists.

I appreciate your optimism, which I am known to share on most occasions, but we have to accept the fact that bad things absolutely can happen and we need to be aware and push back. If you spend a minute digging in to the cratering of EM as a specialty, it is clear that decisions were made that decreased the leverage of well trained attendings to set expectations around their work experience, and a concerted effort was made by HCA to dramatically increase EM residency spots to alter the market in their favor. This may not impact everybody, but a motivated doctor hoping to work in a rural and underserved area might have to accept a much worse arrangement because they will be competing with a large labor pool with very limited bargaining potential. It is both true that you can do well as a psychiatrist and that some positions are less favorable than they were because institutions have responded to physician push back by adjusting staffing strategies. There is a very high risk of this happening here. As to the scope of this issue - I don't have systematic data, but in my class of 220 medical students, there were 2 who came to the US and probably 40 who went to the UK, Canada, New Zealand owing to the fact that they did not need to do a residency. There is really a very large potential supply.

 

[voxveritatisetlucis]

They don’t even need to practice rural. Why would Massachusetts have a bill like this when one can get an apointament with any specialist within two weeks

 

[Mad Jack]

In addition to the issue with education not being standardized globally, the removal of residency training as a bottleneck will drive down compensation as saturation is a likelihood with a change like this.

This is the goal of the legislation, no doubt. This isn't being passed with patients or physicians in mind.

 

[Mad Jack]

So the big issues these candidates will face are manyfold. The first is that the medical board, ultimately, is the one that issues the license and determines whether their qualifications are adequate. The next is that they would not be eligible to accept insurance under any insurer I know of, having not completed US training. Next, they would be ineligible for malpractice coverage unless it was provided by the institutions themselves. Next, they would have to be paid a fair wage to obtain a visa, which would be equivalent to a US physician salary, and would limit the incentive to use this pathway. And finally, there is the fact that malpractice cases would likely fall squarely on the employer, as they would be the ones essentially vouching for the applicant's ability to perform the duties they state they can, and thus if malpractice occurs it would fall on the employer to have certified someone who was incompetent within their field. I don't see it as a big threat for now, as massive legislative, insurance, and reimbursement changes would need to be made to make it workable in any sense of the world.

 

[SmallBird]

So the big issues these candidates will face are manyfold. The first is that the medical board, ultimately, is the one that issues the license and determines whether their qualifications are adequate. The next is that they would not be eligible to accept insurance under any insurer I know of, having not completed US training. Next, they would be ineligible for malpractice coverage unless it was provided by the institutions themselves. Next, they would have to be paid a fair wage to obtain a visa, which would be equivalent to a US physician salary, and would limit the incentive to use this pathway. And finally, there is the fact that malpractice cases would likely fall squarely on the employer, as they would be the ones essentially vouching for the applicant's ability to perform the duties they state they can, and thus if malpractice occurs it would fall on the employer to have certified someone who was incompetent within their field. I don't see it as a big threat for now, as massive legislative, insurance, and reimbursement changes would need to be made to make it workable in any sense of the world.

Those issues are all much smaller than the one that the legislation has removed. There is precedent - people who come from overseas to do fellowship here without US residencies can get medical licenses if they have Step 3 and get paid low salaries because they can index it to other non-fully independent physicians (like residents). I'm not saying there aren't hoops but I think they can be worked through. IMGs in residency are able to practice just fine with malpractice and licenses and work visas etc.

 

[Mad Jack]

Those issues are all much smaller than the one that the legislation has removed. There is precedent - people who come from overseas to do fellowship here without US residencies can get medical licenses if they have Step 3 and get paid low salaries because they can index it to other non-fully independent physicians (like residents). I'm not saying there aren't hoops but I think they can be worked through. IMGs in residency are able to practice just fine with malpractice and licenses and work visas etc.

It'll probably take more years than we'll be in practice for it to be a real issue. And if it becomes one, well, time for me to get that fourth degree in law so I can make a fortune suing the hell out of these systems in malpractice suits.

 

[voxveritatisetlucis]

Do they really have to pay them a competing wage? How is that proven? Like paying equivalent to the lowest paid attending? Even still the two year waiting period makes it a huge issue because even if they paid a competing wage initially, it would still flood the market

 

[brazilianpsych]

I feel that there is a lot of miss information out there. I do not like the law, but this already happens in all the states (or most of them). Big institutions can give temporary licenses and people can practice without residency. I am surprises y'all never heard about it. I know even neurosurgeons practicing this way. They have no problem with insurance or malpractice, although they cannot get licensed outside the institution and cannot practice other places.

 

[SmallBird]

I feel that there is a lot of miss information out there. I do not like the law, but this already happens in all the states (or most of them). Big institutions can give temporary licenses and people can practice without residency. I am surprises y'all never heard about it. I know even neurosurgeons practicing this way. They have no problem with insurance or malpractice, although they cannot get licensed outside the institution and cannot practice other places.

I don't believe you. Other than during training? Evidence?

 

[ObsequiousAplomb]

I don't believe you. Other than during training? Evidence?

I definitely met doctors like that when I was in med school rotations.

Example: catholic charity hospital, profoundly understaffed. A physician who had been a vascular surgeon in his home country was employed for at least the 10 years prior to my meeting him at that hospital. He was employed as a house staff physician and all he did was place central lines, chest tubes, and other bedside procedures. Everyone loved having fewer procedures to do plus he was excellent at teaching these procedures to residents and medical students.

Honestly, afaik he may have had an internship in the US, but I really don't know. I was under the impression he was practicing without any formal US training though.

 

[splik]

I don't believe you. Other than during training? Evidence?

I'm suprised you haven't heard of this. It's usually academic institutions that sponsor surgical specialists, radiologists, anethesiologists etc from other countries who have no residency training in the US. Depending on the state they don't have to do the USMLEs and can get a special faculty permit (in california you have to be appointed at the full professor level to get this). Several specialities allow board certification for specialists trained outside of the US (e.g. peds, radiology, anesthesiology). The ABPN allowed equivalency for international training until 2005.

 

[Stagg737]

I don't believe you. Other than during training? Evidence?

One of our state psychiatric facilities near where I work has multiple physicians who are only allowed to practice at that facility and have their licenses directly tied to the medical director. Some are international physicians who otherwise could not practice here, some are d/t disciplinary action or board problems.

Missouri also has the Assistant Physician position which could also technically fit this definition (must have completed medical school plus Step/Level 2). None of these are neurosurgeons, but I wouldn't be shocked considering some states let NPs run ICUs without any physicians present.

 

[SmallBird]

I'm suprised you haven't heard of this. It's usually academic institutions that sponsor surgical specialists, radiologists, anethesiologists etc from other countries who have no residency training in the US. Depending on the state they don't have to do the USMLEs and can get a special faculty permit (in california you have to be appointed at the full professor level to get this). Several specialities allow board certification for specialists trained outside of the US (e.g. peds, radiology, anesthesiology). The ABPN allowed equivalency for international training until 2005.

I stand corrected, I did not know this!

 

[voxveritatisetlucis]

Yes but this seems totally different than hiring a bunch of people to work in academia. Seems like it’s mainly just to oversaturate the labor market

 

[FlowRate]

I don't believe you. Other than during training? Evidence?

Just as another interesting example, a bunch of teaching faculty at the dental school where I did med school were under the same situation. Licensed to practice just at the dental school.

 

[brazilianpsych]

Yes but this seems totally different than hiring a bunch of people to work in academia. Seems like it’s mainly just to oversaturate the labor market

I completely agree. Most of the people that I know in academia in this setting have great research background and were hired because of that. It was something created so places could get great researchers around the world. I was always skeptical that at one point this would be abused, and it seems that Tennessee is going for that route.