Changing one rule can mitigate the pending doctor shortage

There is an impending shortage of doctors expected in the coming decade. Such shortages could lead to reduced access to healthcare, which could have numerous deleterious effects for all kinds of patients and the most vulnerable Americans. Because it takes years and many thousands of dollars to educate and train effective physicians, the time to address this predicted shortage is now.

In addition to expanding STEM education and developing new crops of American medical students, there is an avenue that U.S. policymakers should consider: there are thousands of legal United States residents trained in medicine abroad who are currently not allowed to practice medicine here. International medical graduates (IMGs) are an underutilized resource that can supplement the current medical workforce.

In their 2020 report, “The U.S. Health Provider Workforce: Determinants and Potential Paths to Enhancement,” published in Perspectives in Biology and Medicine, Jeffrey S. Flier and Jared M. Rhoads examine the institutions that shape the health care job market: the licensing boards, the medical schools, the training programs, and the malpractice insurers that form the medical ecosystem. They describe a web of laws, regulations, and gatekeepers that serve as barriers to entry for untold numbers of potential health care workers. In the United States today, IMGs represent roughly 23 percent of the practicing licensed physicians, but many others are not practicing. Flier and Rhoads, citing Young et al. (2011), report that “There may be as many as 60,000 unlicensed IMGs” in the United States who are “in an array of positions outside of health care.”

The reason for their exclusion is not obvious. A number of accredited international medical schools are already recognized by state medical boards. There are many vetting checks in place that international medical graduates need to pass, including an extensive, multiday test called the United States Medical Licensing Exam (USMLE). The test is sponsored and controlled by the Federation of State Medical Boards and the National Board of Medical Examiners.

According to Flier and Rhoads:

“Pass rates in 2018 for first-time takers of the Step 3 clinical skills exam (taken at the end of the first [graduate medical education] year) were 98% for [medical doctorate] graduates of U.S. and Canadian schools and 90% for IMGs. Whether the modestly lower pass rate for IMGs represents the quality of the pool of students, the quality of their education, their English language proficiency in a test-taking scenario, or other factors is not known.” (internal citations omitted)

Thus, although there is a lower USMLE pass rate for some IMGs relative to their North American peers, nine out of ten pass this rigorous test.

But even if an international medical graduate successfully navigates all these hurdles, she faces another barrier to an American medical career. In order for a candidate to receive certification from the Educational Commission For Foreign Medical Graduates, she must gain admittance to a U.S. or Canadian medical residency program. On the surface, this seems like a reasonable requirement, but it may pose an outsized barrier to entry relative to its benefits.

To begin with, there are not enough U.S. residency positions for all eligible candidates, and the available positions heavily favor recent graduates of American medical schools. Flier and Rhoads note that, in 2020, the residency match rate for U.S. allopathic school graduates was 93.7 percent, compared with only 61 percent of IMG applicants.

The IMGs are at a considerable disadvantage for U.S. residencies, and the residency requirement precludes candidates from completing their medical residencies elsewhere. What's more, even decades of practice in another country (besides Canada) cannot overcome the residency requirement, thus an established doctor in Germany would need to attain and complete a relatively low-paying three-year residency before she could practice in the United States. If there were ample residencies available, perhaps this requirement would make sense, but that is not the world we live in.

The medical residency requirement thus limits the number of medical school graduates that can become licensed in the United States, even if they complete a residency in other countries. The requirement creates an artificial barrier that prevents qualified doctors from providing needed care to American patients.

Changing the U.S. residency rule may bring tens of thousands of qualified physicians into the American health care workforce.