Is doctoring a “job Americans won’t do”?

Or, by tight medical-school admissions, high tuition rates, and the long hours of residency, have we made it into one?

Among the innumerable articles on the dreadful effects of Trump’s temporary 7-country entry ban is this one from the Chicago Tribune, “Travel ban uncertainty worries hospitals, med students as Match Day nears,” which starts with the human-interest angle of a Sudanese-trained doctor worrying that the ban will prevent him from getting his hoped-for residency in the United States.

Now, the article doesn’t explicitly specify that the doctor intends to remain in the United States, but it implies this later in the article, which strikes me as, well, a bit disturbing for a country with a physician ratio of 0.28 doctors per 1,000 people to be sending its citizens to a country with a ratio of 2.45 doctors per 1,000, though, of course, what’s going on seems to be that the upper class in Sudan as well as a variety of other third-world countries comes to the U.S. for residencies and then secures the necessary visas to stay on.  (See the CIA Factbook for these statistics.)

And the Tribune places this in a broader context:  we need these non-citizen residents because

. . . hospitals in Illinois and across the nation rely heavily on doctors from abroad.

Last year, about 14 percent of residents who matched through the main matching program — more than 3,700 people — were non-U.S. citizens who graduated from medical schools outside the U.S., according to the National Resident Matching Program. This year, more than 42,000 people are expected to apply for 32,000 residency spots across the country, in all.

What’s more,

The Association of American Medical Colleges projects that the U.S. will have a shortage of between 46,100 and 90,400 doctors by 2025. Doctors from other countries can help ease that gap, said Dr. Atul Grover, executive vice president of the association.

Here are some more statistics:

In 2015, 18,705 students graduated from American medical schools.  The only data I was able to find on how many of these were non-Americans came from 2010, when a total of 171 students came from outside the United States, which is a surprisingly small number (perhaps it’s increased in the meantime), attributed to the difficulty in gaining admission to medical school from non-US universities.  On the other hand, comparatively larger numbers complete their medical education abroad and then seek residencies in the United States:  a Slate article reports that 12,380 doctors attempted to match from medical schools outside the United States, and 6,301 succeeded, out of a total of 27,293 “PGY-1” available positions (2015 data; PGY-1 seems to be the standard program for medical school graduates and there are about another 3,000 positions which seem to be for those who have already completed some residency); for 2016, the Tribune’s 3,700 non-US citizen, non-US medical school graduates seem to be relative to a total of 27,860 PGY-1 spots (at least, this get you to their cited 14%), the corresponding 2016 data is here.   How to make sense of this data isn’t entirely clear — it doesn’t seem to be the case that U.S. medical school graduates losing out to foreign would-be residents, but just that there aren’t as many students graduating from U.S. medical schools as the need, based on residency slots, would suggest.

And the residency positions, as described in the Tribune article, are lucrative for the hospitals at which they train; they are paid about $50,000 but work long hours.  What’s more, according to The Hill, the residency slots are actually funded primarily by the government, not the hospitals themselves (the exception is that foreign medical schools, e.g., in Grenada, spring for slots for their graduates), based partly on budgetary constraints and partly on projections of “need”.  It seems to me that at some point I read that it’s actually the Medicare budget that contains this funding.

And the larger context is a projected shortage in doctors.  According to the New York Times (and surely only one of many such articles),

The Association of American Medical Colleges has projected that by 2025 there will be a shortfall of between 46,100 and 90,400 doctors. In primary care, it projects a shortfall of between 12,500 and 31,100 doctors.

The baby boomers are getting older and sicker, and they have more complex conditions than they did when they were younger, including arthritis, high blood pressure, pulmonary disease, diabetes and cancer. The Affordable Care Act is expected to accelerate the need for additional medical care. Increased insurance coverage increases demand, and Obamacare alone is projected to require about 16,000 to 17,000 more physicians than would have been required without it.

The Times follows this up by making the argument that we don’t really need more physicians, but rather need to move to delivering more of the medical services that people need by physicians’ assistants and licensed nurse practitioners.  The Tribune, on the other hand, and other similar articles, seems to put this, too, into the category of “jobs Americans won’t do” — which simply doesn’t make sense to me, considering that, at the same time, we’re constantly talking about the fact that rote mechanical jobs will dry up and Americans will have to expect to work at jobs requiring a higher level of skill.  Yes, sure, what with an aging population, there will be an increasing need for doctors and medical professionals of various kinds relative to the size of the working-age population, but are we really saying that there are not proportionately enough Americans with the intellectual capacity to practice medicine?  Or is what’s really going on that, at all levels — lawmakers, government officials, policymakers, hospital administrators, medical school directors — it’s easier to maintain the status quo and recruit from abroad than make the sorts of changes that would bring more Americans into the medical profession?

Let’s face it:  there are substantial obstacles to practicing medicine.  Unlike the typical case (so far as I understand) abroad, where university students study medicine from the start, the U.S. requires a bachelor’s degree before even beginning to study medicine in a specialized manner.  Medical school tuition is so high as to mean that students, from the outset, adopt a mindset of earning a high income.  Residencies, which could be considered the start of one’s professional career (considering that in other fields a fair amount of “on the job training” also happens before one can work independently) instead require so many hours and are, in general, structured such that it requires placing a personal life on hold — or at least that’s my understanding, and if that’s not the case, I doubt the message is getting to students who might be considering a career in medicine.  If the entire system dissuades all but the most determined (and foreigners who are willing to put up with this for the sake of coming to America), then maybe the system needs fixing, rather than relying on importing doctors from abroad.

I am not an expert in medical training systems in, for example, Europe.  I have the vague impression that there are not nearly as many obstacles and nothing like the projections of shortages we have here, but my various attempts at finding out from google aren’t getting me anywhere.  Readers, what do you know?

Image:  https://commons.wikimedia.org/wiki/File%3ADoctor_examines_patient_(1).jpg; By Unknown photographer [Public domain], via Wikimedia Commons