Is your anesthesiology department – like mine – struggling to find qualified anesthesiologists to recruit? Are you worrying nearly every day about how to cover your ORs as well as all the non-OR sedation sites?
The irony is that thousands of American citizens graduating from medical schools abroad would love to come home to practice in the U.S., but we don't have residency positions available for them. These U.S. International Medical Graduates, known as USIMGs, could increase patient access to care and relieve our workforce shortage at the same time if we can find ways for them to finish their residency training.
Consider the plight of Yasmeen El Sayed, MD, an American citizen born in the U.S. and a graduate of St. George's Medical School in Grenada, who has tried unsuccessfully to match to an anesthesiology residency position since 2019. Burdened with $400,000 in medical school debt, she filed 100 residency applications in 2023 but received only five interviews, and once again this year she didn't match. Through the scramble, she found a place in a preliminary internal medicine program and will try once again for an anesthesiology residency in 2024.
“In the context of today's congressional battles over the federal debt limit and spending priorities, why would the government be willing to spend more money on creating new residency positions? The answer is simple: it makes financial sense for the government.”
Across all specialties, 5,046 USIMGs – to underscore the fact, all of them American citizens who trained overseas – took part in the 2023 National Residency Matching Program, and 46% of them, or more than 2,300, failed to match. Some, like Dr. El Sayed, were recurring applicants who had failed to match in previous years. These young physicians want to work, and we have plenty of work to be done. How can we solve this unhappy mismatch?
“Adopt a Medical School”
Solutions are in the works, though these problems won't disappear overnight. I have the honor of chairing the White House National Committee on Foreign Medical Education and Accreditation (NCFMEA). I also serve as the committee's parliamentarian. We understand that residency programs have legitimate concerns about the quality of offshore medical education. My job is to lead the evaluation of each foreign medical school that enrolls Americans and make sure that it qualifies for accreditation by meeting U.S. medical standards.
We are launching a proposal – known as the “Adopt a Medical School” program – that we hope will create ongoing relationships between American and foreign medical schools. If a U.S. medical school “adopts” a foreign medical school, the concept under development is that the two schools could pool resources such as faculty, curricula, and training opportunities, and in the process they would get to know each other. The international school would bolster its qualifications for accreditation, the American citizens training there would have a better chance of matching into residency positions in the U.S., and the American mainland students could enjoy the benefit of safe, accredited offshore rotation experiences in global health care delivery.
Best of all, each participating American medical school would qualify for new government-funded residency positions – beyond the number of positions capped under the 1997 Balanced Budget Act and thus outside of CMS funding constraints. Under this proposal, 80% of the new positions would be dedicated for USIMGs, while the remaining 20% would be reserved for mainland U.S. medical students who fail to match. In 2023, 1,292 students from mainland U.S. medical schools didn't match into positions in anesthesiology and were forced to scramble for positions in other fields or wait for next year's match. This program would help create new positions for them too and ease our workforce shortage.
What's in it for the government?
In the context of today's congressional battles over the federal debt limit and spending priorities, why would the government be willing to spend more money on creating new residency positions?
The answer is simple: it makes financial sense for the government. Many USIMGs finance their education through the federal William D. Ford Federal Direct Loan Program. When they can't complete their training, they can't be licensed to practice or earn enough money to pay back their student loans. The government stands to forfeit literally billions of dollars. Creating new residency positions for these medical graduates is a sound investment from the federal point of view.
Today, we are working closely with U.S. Secretary of Education Miguel Cardona to finalize a resolution that will be presented to President Biden for approval of the “Adopt a Medical School” program and then moved forward to Congress. We are approaching American universities to introduce the idea and, we hope, create the first partnerships between American and international medical education programs.
Other legislative remedies?
Two other bills designed to alleviate the shortage of physicians are currently on the table in Congress, spurred by the prediction of the Association of American Medical Colleges (AAMC) that there will be a shortage of as many as 139,000 physicians both in specialty and primary care within the next 10 years.
The Resident Physician Shortage Reduction Act (S. 834) was introduced in the Senate in 2021. This bipartisan bill would increase the number of residency positions eligible for graduate medical education payments under Medicare for qualifying hospitals. Current law provides for an increase of up to 200 positions per fiscal year beginning in FY 2023, with a total increase of 1,000 positions; each hospital may receive up to 25 additional positions. The bill provides for an additional increase of 2,000 positions per fiscal year from FY 2023-FY 2029; during this period, each hospital may receive up to 75 additional positions in total under the bill and current law. As of this writing, Congress has allocated funding for the new residency positions, but the process has been bogged down within the bureaucracy of CMS, delaying implementation indefinitely.
The Increasing Competition for Medical Residency Act (H.R. 8131), introduced in the House of Representatives last year, would repeal the antitrust exemption enjoyed by the National Residency Matching Program and allow the creation of competing alternative residency programs outside of CMS funding and outside the control of the Accreditation Council for Graduate Medical Education. This bill came before the House Judiciary Committee and has been referred to a subcommittee.
What can anesthesiologists do to help?
No single person can solve our workforce issues alone, but there are three ways in which every anesthesiologist can help.
Get involved and stay involved with ASA and your local state component society! I was nominated to the NCFMEA initially because of my long-standing interest in medical education at Montefiore Medical Center, my work with ASA developing the mentoring grant program, and my involvement with the Society for Education in Anesthesia. Once I had been formally interviewed, The White House contacted me again, invited me to chair the committee, and requested that I become the official parliamentarian due to my long experience as Speaker of the House for the New York State Society of Anesthesiologists. You never can predict in advance how valuable volunteer experience in ASA and your state component society can be in furthering your personal career and helping you develop leadership skills that you can use on behalf of the profession of medicine.
If you're currently involved in academic medicine, I would welcome the chance to connect with you and explore whether your medical school might be a potential partner for an international medical school in our “Adopt a Medical School” program. This could be the pathway toward new residency positions and great new opportunities for your residents to learn first-hand about global health needs. Please contact me: tstraker@montefiore.org. If you're in private practice and you can think of faculty from your past residency program who might be interested in working with us, please send me their contact information. Every contact is worth making when it comes to finding ways for our hard-working USIMGs to complete their training here at home and fulfill their professional dreams.
Become involved in our advocacy efforts if you aren't already, at your own state level and nationally through the ASA! Get to know your state legislators and your congressional lawmakers in the House of Representatives and in the Senate, and please engage with the advocacy efforts of your state society and ASA. When legislation that matters to our profession comes up for debate, we need those personal contacts with legislators to explain to them how serious the workforce shortage is and why we need more residency positions to train American physicians. Your voice and your vote matter!
Every person who helps in all these efforts is working in the long run for excellence in physician training, the future of anesthesiology, and the safety of all our patients. Thank you!
Tracey Straker, MD, MS, MPH, CBA, FASA, Chair of National Committee on Foreign Medical Education, Vice Chair of ASA Fundamentals of Anesthesia, Vice Chair ASA Professional Diversity Committee, Professor and Vice Chair Clinical Operations and DEI Officer Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York.
Tracey Straker, MD, MS, MPH, CBA, FASA, Chair of National Committee on Foreign Medical Education, Vice Chair of ASA Fundamentals of Anesthesia, Vice Chair ASA Professional Diversity Committee, Professor and Vice Chair Clinical Operations and DEI Officer Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York.
