Bringing Physicians to Underserved Areas

CALIFORNIA: LOOKING TO MEXICO

No one disputes that there is a problem in California. The 2000 US Census found that the state had a population of more than 35 million people, about 31% of whom were Latino.⁴ Yet, nationwide, only about 3% of physicians are Latino⁵ — a situation with the potential to create a huge cultural divide. Add to that a communications gap between physicians and the sizable subset of Latino patients who speak Spanish as a first or only language. Then factor in the historic difficulty of attracting physicians to work in rural areas and with uninsured populations. It all adds up to nearly 1 million Mexican farm workers scattered across the state, few of whom have access to any physician whatsoever, much less one who speaks their language or understands their cultural beliefs.⁶

In response to this problem, the California Hispanic Health Care Association proposed a rather radical solution: Why not import health care providers from Mexico who were already licensed in that country, letting them circumvent the normal licensure requirements in California? The result was Assembly Bill 1045, also known as the Licensed Physicians and Dentists from Mexico Pilot Program. The bill would allow up to 30 physicians and 30 dentists to practice on a three-year nonrenewable license at certain community health centers.⁷ When the bill first passed, supporters hoped to have Mexican-licensed physicians in California by July. However, their plan soon hit a snag, when project organizers were unable to find a medical school willing to provide an orientation program and oversight, as required by law. Without a medical school on board, organizers also have been unable to secure the estimated $1 million to $1.5 million needed to administer the project.⁸

In the meantime, the bill has met with strong opposition from several quarters, including the California Medical Association (CMA). “We feel that lowering the licensure criteria that have been developed over the years is a poor way of fulfilling the needs of society,” says Anmol Mahal, MD, vice chair of the CMA’s board of trustees and himself the product of an overseas medical education. “We’re not against the concept of foreign-trained physicians coming and working in California. To the contrary, foreign physicians are an integral part of our health care system here. In fact, there are presently 1,200 physicians who went to medical school in Mexico who are licensed in California.” What the CMA objects to is a two-tier licensure system with lower standards for a select group of Mexican physicians. Says Mahal, “I have no doubt that, given the chance, the best and brightest medical school graduates from Mexico can pass the same exams that every US medical graduate passes.”

CROSSING THE LINE?

Is crossing the border to find doctors really crossing the line? Several national organizations agree with the CMA’s position that it is, at least when it involves making exceptions for physicians who wouldn’t otherwise meet minimum licensure requirements. Arnoldo Torres, executive director of the California Hispanic Health Care Association, takes umbrage at this criticism and the bill’s chief architect. His association is comprised of nonprofit community health centers with about 60 clinic sites statewide. Most of the sites are in rural communities with high concentrations of Mexican farm workers. “How can the medical association or the medical board say they’re more concerned about the quality of care in these centers than we are?” asks Torres. He insists that the bill’s provisions for medical school oversight are more than enough to guarantee that patient care won’t be compromised. Yet this level of oversight has so far failed to materialize, so the matter seems to be moot — at least until the next legislative session, when Torres says he may ask that the oversight requirement be changed.

The California Dental Association (CDA) also has spoken out against Bill 1045. “We were opposed to the bill based on our concerns that it could create two standards of care,” says Jack Broussard, Jr., DDS, past president of the CDA and the association’s point person on this issue. So far, no California dental school has signed on for the project, either. However, Mexican dentists who want to head north may soon have another option. Under a new CDA-supported law, the state dental board has the authority to certify foreign dental schools as offering an education that is equivalent to a California school. The graduates then would be eligible to take the state’s licensing exam just as if they had graduated from a U.S. dental school — the first time any dental board has recognized an approval process other than that of the US or Canadian national accrediting organizations. So far, one school — the University De La Salle in Leon, Mexico — has received provisional approval for part of its curriculum,⁹ although it doesn’t yet have full approval. It should be interesting to see the results of the implementation of the concept of a state board certifying the educational equivalency of a foreign school.

CALIFORNIA: REPAYING THE DEBT

If not Mexican-licensed physicians, then what? The Medical Board of California has its own answer, in the form of Assembly Bill 982, also known as the California Medical and Dental Student Loan Repayment Program.¹⁰ The medical half of the new program, dubbed the California Physician Corps, encourages recently licensed physicians to practice in underserved areas by providing for repayment of their student loans up to a maximum of $105,000. In return, the physicians agree to work in an underserved area for three years.¹¹ In 2003, funding for the program came from $3 million set aside by the medical board from its own budget. The board is currently looking for outside financial support that would allow it to continue the program in future years.

This is the first board-sponsored loan repayment program in the country, and it has so far met with an enthusiastic response. The bill didn’t become law until January 1, 2003, and the deadline for applications was April 11,¹² which didn’t leave the board much time for publicizing the program. They expected perhaps 40 or 50 physicians to apply. “Instead, we received more than 150 applications, so we were pleasantly overwhelmed by the amount of work we had to do,” says program manager Kevin Schunke. Eventually, the board whittled down the list of applicants to 32 awardees. (Some with smaller outstanding loan balances received less than the full $105,000.) Preference was given to applicants who had completed a three-year residency in family practice, internal medicine, pediatrics, or obstetrics/gynecology. However, up to 20% of the awards were available to physicians from other specialties.¹³

Applicants were required to have a current medical license and meet at least one of four criteria: speaking a designated language other than English, coming from an economically disadvantaged background, having significant training in culturally and linguistically appropriate health care delivery, or having three years of experience working in medically underserved areas. In a brochure announcing the program, the board stated several goals, including “improved quality of healthcare, increased access to health services, reduced medical errors, and greater provider-patient trust and satisfaction for limited-English proficient populations.”¹⁴

“One frequent complaint we hear from new physicians is that a big reason they became doctors was so they could help those in greatest need,” says Schunke. “Many have a true dedication to working with underserved populations, but, faced with the burden of massive student loans, they can’t afford to do so.” The intent of the program is to offset financial factors that dissuade new physicians from practicing in inner city clinics or rural community health centers. Schunke adds, “Hopefully, some of the award recipients will spread roots in the community and decide they want to stay there even after their three years are up.”

FLORIDA: MAKING EXCEPTIONS

California isn’t the first state to consider special licensure avenues for certain foreign-trained physicians. Florida, another populous state with a large Latino population, began experimenting with alternate licensing pathways for Cuban and Nicaraguan exiles as far back as the 1970s.¹⁵ The last administration of an alternative licensing exam occurred in 2001. Despite several efforts, the final verdict seems to be that the test failed to make the grade.

In 1974, the Florida legislature required that all the professional boards in the state (including the Florida Board of Medicine) create continuing education programs for individuals who had lawfully practiced in another country before that time. Anyone who passed the continuing education classes and the state licensing exam was to be granted a license. Both the coursework and the exam could be translated into a language other than English. In response to these requirements, the medical board developed a state exam that was translated into Spanish. A few years later, new legislation narrowed eligibility for the special licensure program to qualifying Cuban exiles. The exam was offered until 1979, when Florida joined the national movement toward standardized testing and began using the predecessor of the United States Medical Licensing Examination (USMLE).¹⁶

In 1986, a new law was enacted in Florida that allowed exiled Cuban physicians to complete a special preparatory course developed by the University of Miami in lieu of the Educational Commission for Foreign Medical Graduates (ECFMG) certification, which was required for other foreign-trained physicians. Three years later, this option was also made available to certain Nicaraguan exiles. Oddly enough, the standards set for these two groups differed. For example, while Cuban physicians were required to achieve a certain score on the final course exam, the Nicaraguan doctors were not.¹⁷

More exceptions to the exceptions soon followed. In the early 1990s, members of the physician-exile community began to complain that the $10,000 price tag for the University of Miami program was too steep. In 1992, a second, less costly course developed by the Kaplan company was approved as well — a move that only heightened the controversy and confusion. All told, 198 individuals completed one of the courses, including passing the approved course exam. Of these, 32% went on to pass the licensing exam and be granted a one- or two-year restricted license. Ultimately, while these two special programs were in place, 111 Cuban and 25 Nicaraguan physicians obtained full licensure.¹⁸

FLUNKING THE TEST?

Both of these programs came to an end in the early 1990s. However, the idea of a special licensure pathway was still alive and well. In 1995, several bills were introduced that would once again have exempted certain foreign-trained physicians from the usual licensure requirements. By this time, the USMLE had become the standard licensing exam nationwide. A report that year by the Florida Office of Program Policy Analysis and Government Accountability concluded that the legislature should “reject future requests for special licenses and use the [USMLE] certification process for all foreign-trained and domestic-trained physicians.”¹⁹ Nevertheless, legislation passed the next year that called for the development and administration of an alternate exam, dubbed the Florida Medical Licensing Examination (FMLE).

To be eligible to sit for the FMLE, candidates had to have documentation of at least two years of active medical practice in another country and to have completed either the University of Miami or Kaplan course. “I think the majority of the candidates were individuals who, when they left their home country, the country was less than willing to send us their documentation that they had been doctors there,” says William Parizek, a spokesperson for the Florida Department of Health. The law called for the FMLE to be administered five times within five years. Those administrations occurred between May 1999 and November 2001. After the first administration, when the pass rate was only 4%, the test was translated and offered in Spanish as well as English. Nevertheless, pass rates stayed very low, between 2.3% and 11.1%. A total of about 90 individuals eventually passed the exam, which reportedly cost approximately $2.3 million to develop and administer.²⁰

Not surprisingly, this test — the only alternative to the USMLE offered by any state — attracted controversy. Faced with a lawsuit charging that the FMLE was biased and unfair, the state eventually spent $90,000 to pay physicians who had already passed the USMLE to take part in a study to evaluate the test. Study participants were given $600 to take the test and six continuing medical education (CME) credits if they passed it. Forty-five percent passed, a respectable percentage according to the state, given that the only incentive for actually passing was CME credits.²¹ Meanwhile, a number of organizations, including the Florida Medical Association’s International Medical Group section, were lobbying against the test.²² In 2001, a bill was passed stating that “neither the board [of medicine] nor the department [of health] may administer a state-developed written examination after December 31, 2001…It is the intent of the Legislature to reduce the costs associated with state examinations and to encourage the use of national examinations whenever possible.”²³

CANADA: REMOVING THE BARRIERS

Of course, the United States isn’t the only country grappling with physician shortages in certain areas. Parts of Canada also are faced with an urgent need for more physicians. In response, the College of Physicians and Surgeons of Ontario recently announced a new plan that it hopes will bring more physicians into the province. The college has agreed to broaden what it is willing to consider as qualifications for licensure in Ontario.²⁴ Says Jeffrey Turnbull, MD, chair of the college’s Physician Resources Task Force, “We’ve decided to move beyond simply looking at credentials that may have been established a long time ago and instead assess the physician’s practice.”

A new fast-track assessment program has been devised with foreign-trained physicians who are already practicing elsewhere in mind.²⁵ “Historically, we’ve said, ‘If you want to come practice in Ontario, you must have the right credentials,’ ” says Turnbull. That worked fine for physicians trained in the United States, because the two nations share equivalent educational and training processes. “However, it was a real impediment for physicians who might have trained in South Africa, Australia, England, or Ireland, where the exams are not equivalent to ours,” says Turnbull. Under the new system, which has yet to be implemented, this barrier will be removed.

Candidates will first be screened to determine if they meet minimum criteria, such as possessing a medical degree, having a clean record with their local licensing authority,²⁶ and speaking English or French. Once they pass the screening, the candidates’ training and current practice will be reviewed to see if a full practice assessment is necessary. In some cases — for instance, a foreign-trained physician practicing in another Canadian province — an expedited review may be possible. If a full assessment is needed, though, a trained assessor will visit the candidate’s office for a daylong evaluation, including a review of patient charts and interviews with patients and colleagues.²⁷ “We already do more than 1,000 of these kinds of practice assessments each year with our physicians in Ontario to ensure that they’re competent,” says Turnbull. “So we’ve got some experience with this. All we’re doing now is taking that experience, adding a few things, and moving it to another environment.”

Based on data collected in the assessment, some candidates may be deemed immediately eligible for a license authorizing them to practice independently. Others, however, will need to go through a final stage known as practice validation. During this stage, the candidate will be given a restricted license and required to practice under supervision, participate in ongoing assessments, and pursue continuing education. Upon successful completion of this stage, which can last up to a year, the candidate will receive a license for independent practice.²⁸ The college will start small, first looking at foreign-trained physicians who are practicing in other provinces or the United States. However, says Turnbull, “if that’s successful, then we will certainly look farther afield.”

SERVING THE UNDERSERVED

Some state boards have tried other tactics for bringing medical care to underserved areas. For example, the Arizona Medical Board expedites the processing of applications for physicians who plan to work in an area with a critical need. “We’ve let all the rural hospitals know that we’re willing to do this,” says Barry Cassidy, PhD, the board’s executive director. “We can generally get credentials verified in anywhere from 14 to 40 days, which is much faster than the usual process, which can take months and months.”

In New York, there is a law requiring that applicants for a medical license must be US citizens or have permanent residence status. However, this requirement may be waived for foreign physicians who meet all the other criteria for licensure and who agree to practice in an underserved area. The initial waiver is for three years,²⁹ but it can be extended for up to nine years — “a concession to the length of time it takes for people to make their way through the immigration system and gain permanent residence status,” says Robert Bentley, the state’s director of professional licensing. As of January 2003, there were 707 foreign physicians who were practicing in underserved areas of New York under this kind of limited license. The program seems to be successful at not only attracting doctors, but also keeping them in the state. Of 1,140 now-expired limited licenses, 721 were for physicians who went on to become fully licensed.

Still other states have attempted to address physician shortages by expanding the scope of practice for nonphysician health care providers or granting them prescriptive authority. Often, this has led to emotional debates that pit psychiatrists against psychologists, ophthalmologists against optometrists, physicians against physician assistants and nurse practitioners, or anesthesiologists against certified registered nurse anesthetists.

Beyond expertise, medical boards need to bring flexibility and creativity to the table. The problem of finding enough physicians to work in underserved areas is not one that is likely to go away anytime soon. “It has always been a challenge to have providers take care of underserved Americans, whether it’s because of geographic isolation or financial issues,” says Thomas Curtin, MD, director of clinical affairs at the National Association of Community Health Centers. “Nationally, we have a problem with too many specialists and not enough primary care doctors. And within primary care, we have a maldistribution, with too few doctors going to the areas of greatest need.” The most effective solution to the problem will vary from state to state. However, Curtin adds, “We urge all the states to look at the issue in a flexible and innovative fashion.”

Fresh ideas on increasing medical access are always in demand. Nevertheless, the ultimate test of any board-sponsored program must be whether it meets the health care needs of the public without compromising patient safety. The bottom line seems to be that good intentions must be balanced by adequate safeguards. Members of underserved communities have a right to expect the same high standard of medical care and public protection that everyone else receives.