In 2015, 17% of the 12.4 million professionals working as doctors, nurses, dentists, or other health professionals in the United States were immigrants, and more than 25% of the physician workforce are International Medical Graduates (IMGs)1 —clinicians who have obtained their medical degree or residency training outside of the United States or Canada. Foreign-trained physicians come to the United States for a variety of reasons—due to financial reasons, because of better professional development and career options, or for personal reasons such as marriage. A certain number come to the United States as refugees or asylum seekers because they were forced to leave their home countries due to war, persecution, or natural disasters.
It is not known how many physicians whose legal status is refugee or asylum seeker reside, work, or seek employment or training in the United States. Data from the Educational Commission for Foreign Medical Graduates (ECFMG), which tracks statistics about IMGs, has information on US citizen IMGs (US citizens who graduated from a non-US medical school) versus non-US citizen IMGs (those who are not US citizens at the time of medical school graduation), but does not further breakdown the legal status of the non-US citizen IMGs. Of the 12,142 IMG applicants in the 2018 National Resident Matching Program (NRMP), 7,067 were non-US citizen IMGs.2 There are anecdotal reports of refugee physicians working in the service and hospitality industry, and as taxi drivers or janitors.3 This represents a form of “brain waste,” when medical school graduates cannot fully utilize their skills and education in the workplace despite professional qualifications. This leads to 2 outcomes—unemployment or underemployment4—and individual outcomes including dissatisfaction, demoralization, depression, and lower socioeconomic status, and their associated consequences.
To practice medicine in the United States, IMGs must undergo a time and labor intensive, costly process5 to enter Accreditation Council for Graduate Medical Education (ACGME) approved residency programs, which takes an average of 3 years,5 without guarantee of success. Only 56.5% of IMGs participating in the US Match in 2018 were successful in obtaining a first-year position (versus 94.3% success rate for US graduates).6 IMGs who are refugees or asylum seekers face additional barriers including immediate personal and family needs conflicting with career aspiration, post-traumatic stress from exile, lack of information on the complex US licensing process, limited English proficiency, and difficulty documenting foreign credentials (especially if they had to flee their country).7 Refugee physicians as a group likely are undervalued and underserved.
Several countries including the United Kingdom, Sweden, and Turkey—responding to a humanitarian need and possible benefits to their workforce—have set up dedicated programs to retrain refugee physicians or speed up their certification process.8 The United States has been slow to recognize the potential benefits of assisting them in retraining and securing practice.
Educators, program directors, or the refugees themselves often are unaware that a number of private, public, and nonprofit programs exist to help with reintegration.7 The table lists some established programs.
National, Regional, and State-Level Initiatives
Several nonprofit organizations across the United States have established programs to assist skilled immigrants, with a focus on health professionals. The Welcome Back Initiative (WBI) bridges the untapped pool of immigrant health professionals living in the United States and the need for linguistically and culturally competent health services in underserved communities. The WBI is a network of 10 centers in 9 states providing orientation, counseling, and support to foreign-trained health workers.9
Another nonprofit program, Upwardly Global (UpGlo), helps work-authorized skilled immigrants and refugees rebuild their professional careers. UpGlo supports efforts to ensure that qualified and dedicated foreign-trained physicians are able to integrate into the US system.10
A Minnesota-based non-governmental organization, The Women's Initiative for Self-Empowerment (WISE), established the Foreign Trained Professional Recertification Program, which aims to integrate female immigrant and refugee professionals, including physicians, into Minnesota's workforce.11
State Government Initiatives
Selected states have taken active steps to help with the integration of IMGs. In Minnesota, home to 450,000 immigrants and refugees,12 the Department of Health implemented the Immigrant IMG Assistance Program, which provides clinical readiness assessment, career navigation, examination preparation, clinical experience, and residency application support.13
In 2014, Missouri passed legislation creating a new category of licensed professionals, “assistant physicians,” intended for medical school graduates who have not succeeded in securing a residency position. Once licensed under the program, assistant physicians provide primary care under the supervision of a physician (located within a 50-mile radius) in health care shortage areas. This new license was created to bridge the gap between unemployed medical professionals and communities in need of physicians.14 Other states such as Arkansas, Kansas, and Utah have followed Missouri's example and have approved slimmed-down versions of Missouri's law.15 These initiatives are limited to those who graduated from medical school within 3 years of enrollment in the program, which creates a barrier for many refugee and asylum-seeking physicians whose journeys to the United States often span several years through refugee camps or other nations, making them ineligible.
Programs at Academic Institutions
Some initiatives launched by academic institutions provided clinical and research opportunities for IMG physicians. Drexel University College of Medicine Physician Refresher/Reentry program offers structured preceptorships giving IMGs critical exposure to the US system, as well as clinical time with program faculty, fellows, and residents.16
The George Washington School of Medicine Medical Research Fellowship Program offers research opportunities in different medical specialties and support for residency applications.17
The University of California, Los Angeles (UCLA) School of Medicine established a preresidency training program that provides a structured curricular and clinical environment for native Spanish-speaking IMGs with the goal of service in primary care shortage areas.18 A state law allows program participants to engage in supervised clinical training with patients as part of their preresidency training at UCLA.19
New York Institute of Technology College of Osteopathic Medicine created the Émigré Physician Program, which allows IMGs to earn a degree as a Doctor of Osteopathic Medicine after 4 years of full-time undergraduate medical education.20
Medical Associations
A number of state and specialty medical associations with IMG member sections also support IMGs through mentorship programs, leadership roles, resources, and advocacy. Michigan State Medical Society was the first state society to create an IMG section and was instrumental in the creation of the American Medical Association's IMG section.23 It is not known to what extent these associations dedicate resources to helping refugee physicians.
Discussion
At present, to practice medicine in most locations in the United States IMGs must confirm eligibility with ECFMG, obtain ECFMG certification (dependent on passing USMLE Step 1 and Step 2 examinations), obtain experience in the US health care system, apply for residency, complete residency, pass USMLE Step 3 examination, apply to state medical board for licensure, and finally receive license to practice medicine.24 While advocates of this system say it is necessary to ensure the quality of care, some argue that foreign-trained physicians may have better bedside skills due to lower reliance on technology.25 A 2017 observational study showed that older Medicare patients in US hospitals treated by international graduates had lower 30-day mortality rates than those treated by US graduates.26
IMGs who match do well on their licensing examinations and in their fellowship placements. A self-survey from the NRMP in 2018 showed that matched US citizen IMGs and non-US citizen IMGs had mean USMLE Step 1 and Step 2 CK scores that were well above the 2018 minimum passing scores.2 The NRMP also reported an increase of non-US citizen IMGs applying for fellowship in 2018, with a success rate of matching into fellowship at 71% (compared to 87% for US medical graduates).27
According to published reports, the United States will experience a shortage of 52,000 primary care physicians by 2025.28 Rural and underserved areas will be hit the hardest by this shortage. Research shows that IMGs are more likely than US graduates to go into primary care and serve in rural and inner-city settings.29 One study found that 19% of IMGs practice in rural areas, compared to 10% of osteopathic physicians.30 There are thousands of IMGs, including refugee physicians, already in the United States, who cannot use their medical degree and skills because of barriers in a complex fragmented system of licensing and credentialing.7
We also urge these US residency programs for refugee physicians to continue to share data on their successes and challenges to facilitate learning. Added solutions could include incentives for residency programs to support refugee physicians based on local populations needs; strengthening job opportunities that recruit refugee physicians in other clinical roles initially as a means of gaining exposure to the US health care system; creating a centralized scholarship/grant/stipend system to help refugee physicians with the financial burden of licensing and certification; and dissemination of free, easily accessible toolkits with national and state-based resources, communication modules, test-taking strategies, and guidance regarding the application process.8
Finally, we should learn from other countries, expand existing programs, and pass policies to support reintegration of refugee health professionals. Reintegration programs may benefit refugee physicians and the US health care system, especially in physician shortage areas and areas with foreign-born populations.31
Increasingly diverse patient populations in the United States call for an increase in the diversity of the physician workforce. Refugee physicians, on top of clinical skills sometimes honed over decades of experience, bring different worldviews, cultural humility, and distinct linguistic abilities—which all contribute to competence in the practice of medicine.29
Conclusion
As academic physicians and refugee physicians, it is our experience that program directors often neglect to consider the unique skills refugee physicians can bring to medicine. To meet the needs of this unique population, a task force made up of a broad group of stakeholders, including refugee physicians, should be established. Aims include collection and dissemination of data on refugee physicians, and study of US and other nations' programs for refugee physicians and their impact on the participating physicians and the patients and populations they serve.
