Foreign-trained doctors could be hardest hit by efforts to reduce the physician supply.
International medical graduates, or IMGs, are alarmed by recent schemes to cut residency slots, including New York's plan to reduce 2,000 residents positions over six years. The plan garnered HCFA approval last week (See story, p. 10).
New York is a major training ground for IMGs, with half of residents in downstate hospitals matriculating from overseas medical schools, according to the Greater New York Hospital Association.
"In view of the fact that in New York state almost 40% of the house staff is from overseas, this plan would disproportionately have an impact on IMGs," said Faroque A. Khan, chairman of the department of medicine at Nassau County Medical Center in Meadowbrook, N.Y.
Growing pressure to stem the tide of foreign-trained physicians into the U.S. was one factor that prompted the American College of Physicians last month to call for equal treatment of IMGs (See box).
ACP officials said they don't oppose trimming residents, but they do oppose favoritism for U.S. medical school graduates. The ACP represents 89,000 internists, nearly a quarter of whom attended medical school abroad. They are troubled by a proposal being floated in New Jersey to reduce the number of residency slots in the state and give preference for the remaining positions to U.S. graduates.
In 1995, New Jersey's 41 teaching hospitals trained 2,600 residents, more than 55% of them IMGs, said Lynn Nemeth, executive vice president and chief operating officer of the New Jersey Hospital Association.
Hospitals would reduce that number by as much as 38% over five years, to between 1,600 and 2,000. One of the keys to making that reduction would be to replace some IMGs who work at hospitals in underserved areas with other types of practitioners, Nemeth said.
"There is a sentiment that there should be some preference for U.S. medical graduates considering that the bulk of funding for medical education comes from public dollars," Nemeth said.
New Jersey hospitals plan to apply for a HCFA waiver, as New York did.
The U.S. medical establishment has targeted IMGs. Last fall, the American Association of Medical Colleges and the American Medical Association called for federal action to halt Medicare funding of residencies filled by foreign-educated physicians.
The AAMC contends that teaching hospitals have become over-reliant on foreign-trained residents. Between 1980 and 1994, U.S. residencies increased 26% to about 23,500 from 18,700. IMG residents jumped from about 2,700 to about 7,000, accounting for the bulk of the increase, according to the AAMC.
Removing public funding of residencies for IMGs would discourage teaching hospitals from establishing excess positions, AAMC President Jordan Cohen, M.D., said.
"We're not asking that there be a guarantee for any U.S. graduate," Cohen said.
But ACP officials contend that residency assignments should be based on merit, not national origin. "I think it's an anti-competitive stand," said Mahendr Kochar, M.D., governor of the ACP's Wisconsin chapter.
Mary Herald, M.D., who chairs the ACP's membership enhancement subcommittee, said public hospitals rely heavily on foreign-trained residents to treat underserved populations. She said those physicians often stay in the area to practice.
"By slamming the door in a chauvinistic way we may be shortchanging a lot of our people who need care," she said.
IMGs already face an uphill battle once they complete their residencies and stay in the U.S. to practice.
In December, a General Accounting Office report cast a critical eye on federal programs that grant visa waivers to allow foreign physicians who would otherwise be required to leave the country after their residencies to stay and practice in under-served areas instead. Federal agencies reportedly are discussing changes to the administration of such programs. One agency, the Department of Housing and Urban Development, canceled its visa waiver program (Dec. 23-30, 1996, p. 3).
Many IMGs who have entered the U.S. job market believe they are subject to widespread discrimination-a perception backed up by a recent survey sponsored by Irving, Texas-based Merritt, Hawkins & Associates, a healthcare staffing firm.
The survey of 300 primary-care physicians in their final year of residency training showed that 63% of U.S.-trained physicians received 26 or more job solicitations during the course of their residencies, compared with 39% of IMGs.
"There's a perception that U.S. graduates are better trained and have better communication skills than IMGs, and a certain cultural and racial prejudice probably works into it as well," a Meritt, Hawkins spokesman said.