What's the point of J-1 visas in medicine?

[crazylegs]

This new thread is an offshoot from another one in this forum...

I'm late to the game here. Many good points have been made already.

First, let's not confuse racial / ethnic discrimination with IMG selection issues. It's clearly against the law for me to treat two US grads, or two otherwise identical IMG's for that matter, differently based upon their race, national origin, etc. However, it's perfectly acceptable for me to select based upon what medical school you went to, or what clinical experience you have. If I decide, based upon my experience, that graduates of BMS (That's the "Best Medical School") are terrible, I am well within my rights to decide not to interview them, even if their USMLE scores are good. As mentioned above, I often have no idea how good an international medical school is, and hence the importance of US clinical experience.

Another issue not raised previously is about visas. Many IMG's choose to train on an H1b visa, which requires that there not be an equivalently competent US citizen available to do that job. There is no question that this burden is met in FM, IM and some other primary care fields. However, I would have a problem with any foreign citizen getting an H1b visa in Derm, Rads, Anesthesia, etc. There are plenty of qualified US citizens for those positions. Please note that anyone who does not need a visa -- those with green cards, etc -- would be immune to this argument. A discussion of whether the US should offer J visas (training physicians in this country to take that knowledge back to their own country to improve health care there) is a subject for another thread.

Last, a quick comment about exPCM's discussion of the future of IMG's in the US. I agree that as US schools expand, whether MD or DO, there will be a shift from the Carib to those new spots. Presumably, those people who "just missed the cut" and would be the "top" applicants to the Carib, will now get into the US schools. The overall MCAT/GPA of the US schools will go down, and the same for the Carib's. This new influx of US grads will start to saturate the residency market. However, most of this growth is in the DO system, and it remains unclear whether the allo residency programs will simply accept them or not. Regardless, as pressure mounts and the number of residency slots starts to equal the number of graduates, I expect IMG's will get pushed out, and I expect Congress will do so not by trying to regulate the match (which could fall afoul of the anti-discrimination laws), but rather by closing the H1b visa. Without that, the interest of IMG's coming to the US will decrease exponentially.

However, this does beg the question asked in the H1b application -- When is an IMG equivalent or actually superior to a lower performing US grad? It's a tough question. The USMLE's theoretically tell us who is competent to practice medicine and who is not. But it's obvious that this oversimplifies the situation. I mean, if you get a 182 you're competent but if you get a 181 you're not? That's obviously crazy. My experience tends to suggest that those US grads scoring above the 25th percentile on the USMLE tend to do fine, but those below the 25th percentile (when I take them) tend to struggle more in my program -- not all, but much more likely than those with better USMLE scores. So, as a PD, the tough question here is given a US grad with low but passing scores (and an equivalent performance in medical school -- i.e. the bottom 25% of their class) or an IMG with good scores and perhaps some US experience, which is more deserving / the best risk / will make the best doctor / etc.

I'm glad APD brought this up because this is something that has baffled me for a while. Allow me to explain...

I'm a resident in a program that is roughly 40% IMG (most from India) and takes only J-1 visas. I have interacted with several of these residents over the past few months and have come to really appreciate what they bring to the table in terms of medical knowledge. From what they tell me, in India, the general health there is so poor and the access to care is so sporadic that they are privy to seeing a lot of advanced disease as well as opportunistic infections that are for the most part rare or eradicated here in the U.S. They rarely use CT/MRI/other advanced imaging in India and even laugh at the fact that we order daily labs on wards here in the U.S. because where they came from those "luxuries" aren't often available, and the physician is forced to learn how to diagnose and treat using a well-defined physical exam.

One resident in particular is starting a fellowship in Critical Care medicine. He told me that he is planning on going back to India to practice when he is finished and mentioned that a lot of what he has learned here in residency in the U.S. is pointless, because he will not have the means to use advanced and expensive treatment modalities in India. No computerized touch-screen ventilators. No 30-second ABG readings. Daily CXRs for intubated patients? Yeah right, not in India, according to him.

My question is, how exactly are we training these IMGs to better the health care in their home country? They come to the U.S. with an excellent armamentarium, most notably physical exam skills - there's really nothing they can learn from the U.S. populace who are being preventatively screened rather well compared to most third world countries and don't typically suffer from advanced disease simply because it is caught so early. They've already 'been there and done that' as far as seeing patients with such things as stage IV breast cancer complete with classic peau d'orange, etc. Seriously now, when will a U.S. grad ever see that, besides in a textbook?

They are also being trained to utilize some of the best and most advanced medical technology available, yet they will not be able to use it when they go back home to practice. PTCA is a wonderful thing, and just about any American who is diagnosed with severe CAD will get it... but what about the people in India with STEMIs and 90% LAD blockages who do not have this therapeutic option readily available? What are the U.S.-trained Indian cardiologists going to do for these patients then?

So I ask, what is the benefit of an IMG with a J-1 doing his/her training in the U.S.? It seems to me that these IMGs that train in the U.S. are actually going to be worse off than if they had stayed in India for residency. This doesn't make sense to me, and it confuses me even more when I hear these IMGs discounting the fact that they are even training here in the U.S. for the reasons I mentioned above.

Anyone have a clue about this?? I sure don't.

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[LADoc00]

Not to mention a similar program in the UK to the J-1 visa in the US allowed terrorists to essentially slip in with ease...

where is the patriotic act when it might actually benefit you? LOL

 

[masterofmonkeys]

first off the J-1 visa is hardly some sort of charity program that the US runs to spread better healthcare to the world.

In some ways, residents keep medicare/medicaid solvent. They are very very cheap labor working for 20% or less of the pay of anyone else doing their job (i.e hospitalists). You can pay a fellow 15 bucks to see you as an outpatient for your heart failure without insurance. Try doing that with a real life cardiologist. Yeah you have to pay an attending to come in for a few hours as well, but it is still a major cost savings.

And many who have J-1 visas as residents aspire to get H-1 visas in fellowship, thus getting a chance to stay here.

And while the point you make is true for many J-1 Visa holders returning to the country, there are other benefits. For comparison's sake, an ivy league education is highly valued. As an Ivy graduate myself, I'll be the first to say that although the education I received WAS top notch, much of the benefit comes from the label. What's the difference between a Ralph Lauren polo and one from Target? The label. Someone who trained here, and had access to all of those fancy technologies we take for granted, can go back to India and say 'hey! lookie what i can do!' Practical? Perhaps not when the technology they used to be able to do that is far more scarce. But it opens up doors academically and professionally.

That's a great point you brought up about physical exam skills though. 'Whats his BNP?' who cares! he's got dry mucous membranes, no edema, no JVD, and I couldn't hear a crackle if I had a marshall amplifier!

I'm indebted to the FMG resident I had on medicine and his mentoring wrt physical exam.

 

[Llenroc]

Very few people coming over from India intend to go back. Don't confuse your anecdotal experience with the broad trend. Not sure what this has to do with J1 visas. As a general rule, Indian doctors who want foreign training go to England to get an MRCP/FRCP. Those who want to settle elsewhere go to America.

My family came over on a J1, which we had converted to an H1B and eventually a Green Card. We never went back except on holidays. I think the J1 visa, you're supposed to leave the country for 2 years upon completion of your residency, but there's ways around this if you agree to work in an underserved spot.

 

[masterofmonkeys]

^^^ I know where you went to school. And what fraternity you were in.