Let me be a doctor

Why We Have Enough US Citizens to become physicians in the USA without having to employ foreign nationals

What the ACGME, USMLE, AMA, AAMC, ECFMG and ERAS Don’t Want You To Know

On January 27th 2017 President Donald J Trump signed an executive order enacting a temporary refugee ban from seven countries previously on the terrorist watch list, initially put together by the Obama administration. Since its enactment, one of the many ramifications that has gained notoriety by various mainstream media outlets has been the assertion that these immigration restrictions would adversely impact our healthcare system, by making it more difficult for foreign-born medical graduates to be accepted to residency training in our country, leaving many residency spots unfilled and worsening our current national physician shortage.

This assertion, however, is false. In fact, we have a minimum of 3,000 U.S.-citizen medical school graduates who have not been able to gain employment for several years. The National Resident Matching Program (NRMP), the system through which United States and international medical school graduates obtain residency positions in U.S.-accredited training programs, announced the results of the 2016 Main Residency Match (referred hereinafter and colloquially as “the Match”) as the largest application pool on record, encompassing 42,370 registered applicants and 30,750 positions. Among US allopathic medical school graduates, there were 18,668 seniors who applied for 27,860 first year post-graduate training (PGY-1) positions Of those, 18,187 applicants submitted program choices and 17,057 matched to first-year positions, leaving a pool of 1,130 applicants who did not match into residency. That statistic failed to include U.S. allopathic students who have re-applied after failing to match previous years, which amounted to 1,502 applicants. The NRMP also failed to include applicants of Osteopathic medical schools, which make up 2,982 applicants who also apply to ACGME residency programs.

Out of the 5,323 U.S. citizen international medical school graduates (USIMG’s) who submitted program preferences, 2,869 (53.9%) applicants were matched to first-year positions leaving 2,454 USIMG’s unemployed. NRMP reported that the number of non-U.S. citizen IMGs increased to 7,460 applicants. Of the 7,460 IMG participants who were not U.S. citizens, 3,769 (50.5%) matched(ECFMG).

Let's do the math with the numbers we were given, even though those numbers do not accurately account for applicants who apply to residency positions solely using ERAS, which are the real application pool. We have a total of 30,750 first-year residency spots. If we matched every AMG ( american medical graduate); 18,668 previously graduated AMG, 1,502 D.O. graduates (Doctor of Osteopathic Medicine) and 2,982 AMG’s, that would leave 7,598 open positions. ( not understading the data here, we should enter a math diagram here) . If 5,323 USIMGs matched, 2,275 unfilled positions would still be available. . However, this probably is not the case since many more applicants who are U.S. citizens and non- U.S. citizens IMGs actually apply to residency and do not receive interviews.
The real numbers can be calculated through ERAS. The Electronic Residency Application Service, abbreviated ERAS, is a service of the Association of American Medical Colleges (AAMC) through which M.D. and D.O. graduates of medical schools apply to residency and fellowship programs in the United States. It transmits applications, letters of recommendation (LoRs), Medical Student Performance Evaluations (MSPEs), medical school transcripts, USMLE transcripts, COMLEX transcripts, and other supporting credentials from applicants and their designated dean's office to residency program directors. This is where students apply to post graduate residency training programs and receive interviews.
Keep in mind that the percentages reported in the NRMP do not account for applicants that did not submit their rank order list, which would exclude applicants that pre-match (not using the NRMP to rank programs and are offered a “pre-match” contract), applicants who did not receive interviews invitations and applicants who felt hopeless. It is not uncommon for an IMG to be offered interviews, resulting in zero invitations and an empty rank list, thus NRMP's IMG match rate is not accurate. In order to look at the true number of U.S. citizens that apply for residency we need to look at ERAS. (The number of tokens that were issued for all applicants, intended to fill PGY-1 resident positions.) When I chatted with an ERAS/ECFMG representative, I inquired about the number of applicants who have applied for PGY-1 positions, they quoted “around 40,000”. I then asked for an exact number and he redirected me to the NRMP. Logically, I replied that the number he quoted could not be correct because the number (40,000) does not account for the total number of applicants who apply to residency PGY-1 positions. I then asked how many are IMGs apply to PGY1 positions, and he responded, “around 19,000.” I proceeded to ask , how many of the 19,000 are non-US citizens? He would not provide that information and stated “no one has that data.”
Using the numbers quoted by the ECFMG representative, about 21,000 U.S. grads apply for residency positions. So there are about 2,813 U.S. grads that go unmatched and do not apply to the NRMP. Therefore, the USA does not need to outsource U.S. residency positions.
According to the AMA (American Medical Association), there are about 280,000 international medical graduates currently practicing in the United States. That's about 1 in 4 physicians practicing medicine in the U.S. Some are U.S. citizens who've gone abroad for medical school, but most are not. Even residency programs who have foreign program directors in leadership, have started to discriminate against U.S. citizens. Many residency programs no longer update residency profiles online and have even failed to post a pictorial roster of their current graduates with medical school stats.

For example, let’s take a look at information posted on several residency training programs. We can clearly assume that the majority of residents training at Hurley Medical Center/Michigan State University Program in Flint, Michigan are foreign trained, non- U.S. citizens. The program director Ghassan I Bachuwa MD, MS, MHSA coincidentally is also foreign born and trained. In Grand Rapids Michigan, the internal medicine residency program has a soft spot for King Edward's School in Pakistan possibly because of Dr. Nasir Khan’s (P.D.?) background as a Pakistani graduate. Central Michigan University emergency medicine reserve positions for only Saudi Arabia applicants, not even a AMG could fill those residency positions. Cleveland clinic internal medicine residency does not publically publish a list of their trainees. The program however, has posted information about their AMG house staff. Texas Tech University Health Science Center neurology residency , appears to hire only non-us citizens and not one resident appears to be an AMG. Interfaith Medical Center in Brooklyn, N.Y.has also failed to post their residency profiles publically, possibly because there are non-US citizens. Many programs in Ohio, Michigan, Texas, and New York all favor foreign national IMGs over US citizen IMGs.

Clearly, the system is corrupt. The Match and program directors who rank applicants, favor an applicant’s board scores. Infact, when applying for residency training positions, minimum score requirements are posted publically, though application materials and rank lists are based on “preference.” However, the general population including program directors are not aware that the USMLE (U.S. medical licensing exam ) Step 1 and Step 2CK (clinical knowledge) can be taken anywhere in the world. For example, why would India or Pakistan care about enforcing fair and accurate exams for the USMLE? Their economy depends on their citizens immigrating to the U.S. and earning a $200,000 to $1,000,000 USD salary occupation. It is not uncommon for residents and physicians to send portions of their salary back to their country of origin to support their families. Some even plan for relocation and retirement, without actual investments in the American society. India’s system along with many other foreign countries have become notorious for inadequately training doctors. (BBC)(Bennett). It is plagued by rampant fraud and unprofessional teaching practices, exacerbating the public health challenge. These ramifications spread beyond the country’s borders: India is the world’s largest exporter of doctors, with about 47,000 physicians currently practicing in the U.S. and about 25,000 physicians in the United Kingdom(MacAskill, Stecklow, and Miglani). About 45 percent of India’s population who practice medicine have no formal training, according to the Indian Medical Association. These 700,000 unqualified doctors have been found practicing at some of India’s biggest hospitals, giving diagnoses, prescribing medicines and even conducting surgery (MacAskill, Stecklow, and Miglani).

According to ECFMG.org , you can sit for the USMLE Step 1 and Step 2CK anywhere in the world. U.S. hospitals and program directors are unaware whether the same biometric security used to administer these exams are congruent to U.S. standards. The following is a list of countries that administer these tests without any U.S. oversight of their identification security methods:

Africa: Ghana, Kenya, South Africa, and Uganda
Asia: Bangladesh, Malaysia, Nepal, Pakistan, People’s Republic of China, Philippines, and Singapore
Australia: Australia and New Zealand
China: People’s Republic of China
Europe: Armenia, Croatia, Denmark, France, Germany, Greece, Ireland, Israel, Italy, Latvia, Netherlands, Portugal, Spain, Switzerland, Turkey, and the United Kingdom.
India: India
Indonesia: Indonesia
Japan: Japan
Korea: Korea
Latin America: Argentina, Bolivia, Brazil, Chile, Colombia, Costa Rica, Dominican Republic, Guatemala, Mexico, Peru, Trinidad and Tobago, and Venezuela
Middle East: Egypt, Jordan, Kuwait, Lebanon, Oman, Qatar, Saudi Arabia, and United Arab Emirates
Taiwan: Taiwan
Thailand: Thailand

Another disadvantage to U.S. IMGs not acquiring residency positions, or being “unmatched” is student loan debt. The average student debt for a medical school graduate in 2015 was more than $180,000. Twelve percent of graduates had debt totaling more than $300,000. Thus, when U.S. citizens go unmatched, they are unemployed without jobs and without salary to repay these debts. Many have multiple degrees and many medical graduates will default on student loans, which effects our economy. Their years of education wasted, because, to be quite frank, where else can you utilize your medical degree without resident training to actually practice medicine? The answer is, nowhere. The truth is, many medical school graduates find mediocre jobs assuming some financial responsibility unrelated to their degree. The other problem with matching non-U.S. citizens over U.S. citizens is that they usually go to medical school for free. They have no debt. They fill U.S. residency positions, train and return to their home countries.

In conclusion, U.S. citizens are being discriminated against in their own country. Non-U.S. citizens immigrate to the U.S., become head of their departments favoring and supporting foreign born medical school graduates. The foreign born medical students have an advantage over U.S. citizens because the USMLE allows them to take OUR medical boards in their home county where there are no standards. The program directors are usually foreign born and have a bias to accept other foreign naturals. The USMLE, ERAS, NRMP, USMLE, AMA, AAMC are withholding data that reflects our broken system, protecting foreign born doctors and hurting U.S.-citizen doctors and patients.





Citations

BBC. “Vyapam: India’s Deadly Medical School Exam Scandal.” BBC India. BBC News, 8 July 2015. Web. 28 Feb. 2017.http://www.bbc.com/news/world-asia-india-33421572
(BBC)
MacAskill, Andrew, Steve Stecklow, and Sanjeev Miglani. Special report: Why India’s medical schools are plagued with fraud. Reuters, 17 June 2015. Web. 28 Feb. 2017. http://www.reuters.com/article/us-india-medicine-education-specialrepor-idUSKBN0OW1NM20150617
(MacAskill, Stecklow, and Miglani)
Bennett. Proxy examinees caught taking US college entry test. The Times of India, 17 Jan. 2016. Web. 28 Feb.2017.http://timesofindia.indiatimes.com/city/ahmedabad/Proxy-examinees-caught-taking-US-college-entry-test/articleshow/19551486.cms
(Bennett)

“Testing regions and international test delivery surcharges for USMLE step 1 and step 2 CK.” n.d. Web. 28 Feb. 2017.http://www.ecfmg.org/fees/usmle-surcharge.html
(“Testing Regions and International Test Delivery Surcharges for USMLE Step 1 and Step 2 CK”)

NRMP Program, National Resident Matching. Learn more. 2002. Web. 28 Feb. 2017. http://www.nrmp.org/match-data/main-residency-match-data/
(NRMP Program)

ECFMG. “IMG performance in the 2016 match - ECFMG news.” 2016 Match. ECFMG News, 30 Mar. 2016. Web. 28 Feb. 2017.http://www.ecfmg.org/news/2016/03/30/img-performance-2016-match/
(ECFMG)

http://www.nrmp.org/wp-content/uploads/2016/04/Main-Match-Results-and-Data-2016.pdf

http://www.ecfmg.org/forms/factcard.pdf

“United States medical licensing examination.” n.d. Web. 28 Feb. 2017. Performance Data”http://www.usmle.org/performance-data/default.aspx#2015_step-3
(“United States Medical Licensing Examination”)