A New Way To Mitigate Physician Resistance by Aaron Levine MD


Dr. Sanjay Gupta of CNN recently did a story on UCLA staffing inner city clinics with physicians from Latin America countries. For the sake of brevity, the doctors were in the United States, presumably the Los Angeles area, and were working in nonmedical jobs. These included from snippets housekeeping, building trades and lawn care. The doctor interviewed represented the program. UCLA paid for them to study and take American Medical Examinations. I presume the ECFMG or Flex, but neither was specifically identified. Those who passed were trained and they now staff the community clinics. On a positive side, a vital resource is not wasted. These doctors can talk to many of the people in their own language, Spanish. The doctors are presumably paid more than they received for manual labor, get more respect, and (hopefully) better working conditions and prestige. This is to their benefit. No negative sides were mentioned. Money was not mentioned, but presumably they accepted lower salaries than others demanded. This could keep costs down, but may sidestep the clinical training programs traditionally taken in this country.

There was an article in the AMA News more than 20 years ago that stuck in my mind. Some Irish doctors were recruited to staff a hospital directed HMO in upper New York State. The local doctors refused to work for the hospital at the salaries offered. The hospital received some waiver as a physician shortage area due to the HMO needs. The Irish doctors were recruited at a salary greater than the government set salaries in Ireland, but less than the local doctors demanded. The article spoke of how the doctors could be replaced after a few years if they developed unreasonable demands. The community had a bonus. These doctors could speak to the locals in their native language, English.

Many may not recall the debates over the ratification of NAFTA in 1992. Ross Perot described the “sucking sound” of jobs going to Mexico in the Presidential election. Arguments existed over Mexican truck drivers coming to the US. I called the AMA at the time and asked what organized medicine’s position on this was? I was told there was none. Each state licensed its own physicians and was medical licensure was therefore exempt form NAFTA. I pointed out the Senator Rockefeller of West Virginia proposed, separately as a quality measure, a national medical license that allowed doctors to treat people on Medicare and Medicaid but would not allow them to treat individuals otherwise in the 50 States. This bill never passed. The AMA investigated and I received a call about the revised opinion on NAFTA.

We hear of the shortages of PCPs and how PAs and NPs will fill in the gaps. Many older, not yet retired specialists, have discussed retirement and can not be replaced.The costs of the electronic records, reduced reimbursements, the sustained growth debacle, and ICD-10 added to costs that may not be offset by the remaining few years of practice available. Early retirement is then a viable option. This adds to the shortages of specialists that already exist.

Now, either my paranoia is present or I am prescient of a future event. The three events I described above now can be placed into a new perspective. There are 25 million people with health issues being added to the population after the AHCA, let alone millions from revision of immigration policies. Physician shortages are happening. It takes too long to train American doctors. There are comments that I read about shortening medical school and residencies each by a year. This lowers student debt and gets people out as specialists.  But I can also see an new approach to allow immigration and the creation of a license for foreign trained doctors recognized as specialists in their own country. This would allow them to practice here without meeting board certifications (unless reciprocity is also forced). This is not meant to dispute the quality of these doctors. I suspect this action or threat of action will be used to mitigate any resistance by American doctors to the changes coming.