When Julio Lozano, M.D., came from Sonora, Mexico, to Houston in 2006 for a one-year fellowship in hand microsurgery and upper-extremity surgery, his plan, he says, was to return to Mexico to practice. Today, Lozano, 36, is a surgeon with the Reconstructive Orthopedic Center in Hermosillo, Mexico. The move places him among a small minority of international doctors who, after training in the U.S., choose to return home.
Most of the people who train in the United States dont come back to Mexico, because the income is better in the U.S., and there are a lot of opportunities for research, Lozano says. The physician acknowledges that he was lured back to Mexico in part by his countrys growing focus on the profitable medical tourism industry.
But while medical tourism growth in healthcare profit centers such as orthopedic surgery and plastic surgery may be drawing some specialty doctors back to their homelands, the vast majority of international physicians trained stateside are choosing to stay put after completing their residencies and fellowships, according to data from the Association of American Medical Colleges. The organization reports that 27% of all U.S. medical residents and fellows during the 2007-08 academic year were international medical graduates. Nearly 24% of all practicing physicians in the U.S. during 2006 were internationally recruited doctors, according to the American Medical Association.
That reality, public-health experts say, is exacerbating the global problem of healthcare-worker brain drainthe practice of wealthier countries drawing healthcare workers from already-underserved poorer countries. Now, a growing number of U.S. and international healthcare policymakers are calling on medical schools and teaching hospitals to devise strategies geared toward increasing the domestic and global supply of healthcare workers, and encouraging a more equitable distribution of those resources.
The Health Worker Migration Policy Initiative is among the most recent efforts to shine a spotlight on the issue. Launched in May 2007, the initiative is a collaboration between the healthcare policy groups Realizing Rights: The Ethical Globalization Initiative and the World Health Organizations Global Health Workforce Alliancea group focused on addressing the global healthcare worker shortage. Earlier this month, the collaboratives global-policy advisory council released a draft of its voluntary code of practice for international recruitment of health workers. The document recommends a variety of measures, including medical-education and healthcare-infrastructure resource exchanges between wealthier recruiting nations and the countries from which workers are drawn.
The advisory council also has recommended that underserved countries intensify their efforts to retain the medical professionals they educate, and that wealthy countries work to recruit a larger number of their own citizens into healthcare careers rather than rely on foreign applicants.
The groups latter suggestion echoes the AAMCs 2006 recommendation that medical schools increase their student enrollment 30% by 2015 in order to address the U.S. growing shortage of physicians.
Academic medical institutions do appear to be moving in that direction. According to a 2007 AAMC report, 86% of medical schools have increased or are planning an increase in first-year enrollment. The enrollment efforts coupled with plans to open roughly 12 new medical schools should bolster the number of doctors in training roughly 21% by 2012, according to the AAMC.
Countries taking action
Some countries also are making moves to curb their losses of highly trained healthcare workers. In Mexico, for example, Christus Muguerza, a six-hospital system owned by Irving, Texas-based Christus Health, requires all of its physicians and nurses sent stateside for training to sign an agreement to return, says Thomas Royer, M.D., president and chief executive officer of Christus Health. They agree to return for a set period of time that is equal in some way to the amount of money invested, he says.
Healthcare policymakers are also attempting to address allocation of thinly stretched nursing resources.
According to the American Hospital Association, the U.S. has a current deficit of about 116,000 registered nurses. Recruitment of nurses to the U.S. from countries such as Ghana, Nigeria, the Philippines and Zimbabwe is becoming more commonplace, according to Facilitating Acculturation of Foreign-Educated Nurses, an article published in the Online Journal of Issues in Nursing, a publication of the American Nurses Association.
Last month, a task force led by the Washington-based healthcare policy group AcademyHealth issued a Voluntary Code of Ethical Conduct for the Recruitment of Foreign-Educated Nurses to the United States in an effort to address such international recruiting practices. The code includes recommendations for U.S. healthcare organizations to create resource-sharing partnerships with countries from which they recruit.
Addressing the global dearth of healthcare workers will be no simple task, however. The WHO estimates a worldwide deficit of 43 million medical professionals, with the greatest shortage in sub-Saharan Africa, which needs nearly 1 million workers. And while poverty exacerbates the problems for some regions of the world, the root causes of the healthcare-worker shortagewhich includes physicians, nurses and researchersis shared by both rich and poor nations, says Peggy Clark, managing director of Washington-based Realizing Rights.
People are living longer and the need for healthcare is expanding, Clark says. Certainly here in the U.S. we have not kept pace with that changing need. Were not encouraging people to go into healthcare, and were so dependent on foreign workers that weve not really taken a strong stance. Its just sort of easier to import healthcare professionals, she says.
In the U.S., family-practice residencies have traditionally drawn the greatest number of international medical school graduates. Thats because each year, a significant number of family-practice residency spots remain empty following the matching process. The U.S. has never had a strong primary-care system because the money follows specialty care, says James Martin, program director of the family medicine residency program at 388-bed Christus Santa Rosa Health Care in San Antonio. But, if you look at whats needed in this country, its primary care, and a lot of recruiters are looking to international medical students to fill those spots, he says.
As a result, in 2007 more than 38% of the U.S. family medicine residents were international medical graduates, according to the American Academy of Family Physicians.
For some programs, international medical graduates represent the bulk of the physician population. At the medical school of the University of Medicine & Dentistry of New Jersey, Newark, for example, roughly 80% of the current family medicine residents are foreign medical-school graduates, estimates Stephen Baker, M.D., dean of the graduate medical education program. On a broader scale, nearly 35% of all the schools medical residents currently are international graduates, placing it among the states with the highest percentages of international residents.
Carolyn Bekes, M.D., senior vice president of academic medical affairs for 425-bed Cooper University Hospital in Camden, N.J., says that while her organization has been able to recruit roughly 80% of the residents in its programs from U.S. medical schools, New Jersey as a whole is highly dependent on international medical school graduates to fill residency slots. Thats because New Jersey doesnt have a lot of medical schools from which to recruit doctors, she explains.
Plenty to go around?
While Bekes and other medical-education experts agree that current recruitment practices may draw sorely needed healthcare workers away from underserved countries, they are quick to point out that not all international recruits come from countries where there is a dearth of healthcare workers.
India, Pakistan, Nigeria and Mexicowhich rank first, second, eighth and 11th in the number of international medical graduates practicing in the U.S., according to the AAMCall produce per-capita excesses of medical-program graduates, according to international public-health experts. But since such countries often lack sufficient post-graduate training opportunities, healthcare workers there must either leave their homelands for continued training or set up practice right out of medical school in rural areas where there is little healthcare infrastructure.
That is the case for many physicians trained in Mexico, says Constantino Padilla, chief medical officer for Christus Muguerza. We have 22,000 doctors trying to get into 4,000 residency slots every year, Padilla says. The ones who dont match either become pharma sales reps or rural family doctors. They will go out to the underserved areas and try to practice there.
A number of those graduates, however, will come to the U.S. for training, and once they are here and employed, often find themselves in a much better position to financially support the family members they left behind.
Those remittances are substantial and an important part of the equation when you look at the cost to a country when it loses a physician compared to the remittances the doctors send home, says John Norcini, president and CEO of the Foundation for Advancement of International Medical Education and Research, Philadelphia.
Such dynamics, however, have led some healthcare experts to question whether the assumed global shortage of healthcare workers is more an issue of poor resource allocation, with doctors and nurses gravitating to countries and communities that promise the best quality of life and career opportunities.
Currently, about 11% of the nursing staff in the U.S. are international nursing graduates, says Robert Crone, M.D., managing director of the Huron Consulting Group and former president of Harvard Medical International. Theyre mostly young women who would be likely to remain in their (native) communities if they received good pay.
But Wafaa El-Sadr, M.D., an epidemiology professor at the Columbia University Mailman School of Public Health and director of the schools HIV program in sub-Saharan Africa, says that money isnt the only issue that motivates medical workers to leave or remain in their homeland. If you talk to healthcare workers, they will tell you that money is not the primary problem; its the lack of opportunity and the day-to-day satisfaction with the work, she says.
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