By RICHARD W. SAMES The former dean of Natural Science
at Sangamon State University, he is presently assistant to the
vice president for academic affairs at SSU.
Some of Illinois' future doctors train in other countries while foreign graduates staff many hospitals in the state. These foreign-trained doctors must pass a competency test to get license to practice in Illinois. Many can't pass
AN INCREASING number of well-qualified Illinoisansare going abroad to study medicine, and when their education is completed, most of them are not returning to Illinois. At the same time the state has been forced to rely heavily upon foreign medical school graduates (non-American born) to meet its health care needs. Illinois needs more doctors than it has, but its own medical schools cannot handle all the talented students who apply and thus the exodus to foreign schools. Steps are now being taken to accommodate more students at Illinois medical schools (see accompanying article), but as the following discussion indicates, the problem is complex and will not be easily solved.
Foreign medical graduates (FMG's) today make up a significant percentage of the state's doctors. In 1970, 28.7 per cent of all physicians in Illinois were foreign medical graduates. This figure inceased to 31 per cent in 1973. Although this increase is fairly small, the fact that foreign graduates made up 68.9 per cent of the newly licensed physicians in 1973 indicates that the proportion is growing rapidly. The American Medical Association (AMA) reported that in December 1974, 51 per cent of the interns and residents at Illinois hospitals were graduates of foreign medical schools. Many health care professionals believe that this is a disproportionately high number of foreign physicians and constitutes a challenge to the quality of medical practice in Illinois.
As high as the proportions of FMG's are, these figures actually underestimate the number in the state. AMA records list only those FMG's who are fully licensed or who are enrolled in approved graduate training programs in the state. In 1970, for example, 4,542 FMG's were recorded; of these, 2,348 (51.7 percent) were fully licensed, while 2,192(48.3 per cent) were not. At present, official records place approximately 6,500 FMG's in the state, but unofficial estimates of the AMA indicate there are between 1,200 and 2,400 additional foreign physicians in Illinois. Many of these physicians (generally designated as the "underground") are employed in state mental facilities or in other health capacities where they can practice under limited or institutional licenses. The salaries paid to these "underground" doctors are, on the average, well below those paid to fully licensed physicians in the state.
"If it weren't for the foreign physicians, who would run American hospitals?" asks Dr. Robert Devito, supervisor of the John J. Madden Mental Health Center in Hines, 111. "Only five of my 21 doctors are Americans." While acknowledging that only 13 of his physicians are licensed, Devito feels that his institution is in much better shape than most. The dependence on foreign medical graduates not only in state chronic disease and mental hospitals but in acute-care hospitals as well can only be described as substantial.
Diplomatic effects
Many health care professionals find American reliance on FMG's to
be questionable to the point of "morality." "A rich nation
becomes richer at the expense of poor nations," says Irine Butler of
the School of Public Health at the University of Michigan. The lure of big money
and advanced training drains doctors from poor countries that need them far more
than we do. The Philippines, India and South Korea are now our biggest suppliers.
In the past three years Illinois examined or licensed between 25 and 30 per cent of
the annual output of seven Philippine schools. Dr. Kenneth K. Schnepp, chairman of
the Medical Examining Committee for Illinois, has warned of the adverse
August 1976 / Illinois Issues / 17
Illinois medical school applicants, rejected because of space rather than qualifications, find acceptance at foreign institutions
diplomatic effects this could have for the United States. It is clear that the draining of critically needed physicians from underdeveloped countries creates considerable anti-American feeling.
To be licensed in this country, a foreign medical graduate must pass state medical licensure examinations or the examination of the Educational Council for Foreign Medical Graduates (ECFMG). This is a basic requirement for appointment to AMA-approved internship or residency training programs. The examination is in two parts. The first part tests general medical knowledge. Its questions are taken from an examination drawn up by the National Board of Medical Examiners and normally given to American students in the fourth year of medical school. The second part tests knowledge of the English language. On the first try 30 to 40 per cent of the foreign medical graduates pass both parts of the exam, while 90 per cent of American-educated candidates pass. By taking the exam repeatedly, about 75 per cent of the FMG's ultimately pass.
Competence of FMG's
Foreign medical graduates coming to the United States
demonstrate a wide range of professional competence.
Some FMG's meet the most exacting standards of professional
qualifications required for academic appointments to U.S. medical
schools, but large numbers of FMG's, estimated at 10,000, have yet
to pass their exam and so are not legally qualified for independent practice.
The majority of FMG's are somewhere be tween these two extremes.
Unfortunately, evidence suggests that this distribution is heavily weighted
toward the lower range of acceptable professional competence. Nevertheless,
Illinois has been and will be heavily dependent upon FMG's to meet its health c
are needs.
Limited positions
Complicating the problem, in the minds of many,
is the increasing number of Illinoisans who have pursued
their medical studies abroad. The limited number of student
slots in Illinois and U.S. medical schools generally is the principal
reason why so many of our most talented and determined students
leave the country to obtain the M.D. degree. Records show that 2,105
Illinois students applied to Illinois medical schools for the 1973-74
entering class (the most recent year for which reliable data are available).
A total of 631 were accepted. Probably another 600 were qualified and could
have successfully completed medical training. It is this pool of candidates,
unacceptable only because of space limitation, that accounts for the enrollment
of Americans in foreign medical schools.
Foreign medical schools
Confirmation of the abilities of many of those rejected is found in
the performance of students on the Medical College Admission test which
has risen steadily over the years. The average non-accepted applicant
of the 1970's scored higher than the average accepted applicant of the
mid-1950's. Clearly, many of the thousands of applicants rejected each year
by U.S. medical schools are well qualified for the study of medicine; an estimated
6,000 apply each year and are accepted at foreign medical schools.
These foreign medical schools which accept American students are quite
different from our accredited ones; they are less selective, have smaller
faculties. and limited resources for teaching the basic medical sciences.
They cannot provide the carefully supervised tutor student teaching that has
become almost standard in our own system.
Many of the American students in foreign medscal schools seek entry into American medical schools after their second or third year. In the past there has been room at this level of medical education to accept transfer students, and methods were established to identify competent individuals who could finish the program. One of the most important of these methods is the Coordinated Transfer Application System (COTRANS), operated by the Association of American Medical Colleges. Students from foreign medical schools are eligible to take the COTRANS examination following completion of basic medical science subjects. Those successfully completing the examination are eligible for admission to advanced standing in U.S. medical schools, usually as regular third-year medical students. After graduation from an American medical school they are treated no differently than any other graduates. But, as the table indicates, the number of third-year slots in U.S. medical schools is not increasing as rapidly as the number of qualified foreign applicants.
In June 1971, the American Medical Association Council on Medical Education issued a policy statement establishing
18/August 1976/ Illinois Issues
"a new Pathway for Entrance to AMA approved Internship and Residency Programs," Created for foreign medical graduates who had completed their premedical work in an accredited U. S college or university, it is called the Fifth Pathway and is one method used by graduates of foreign medical schools to gain access to AMA approved internships and residencies. The program was specifically designed for
Students from foreign medical schools transferring to U.S.
|
Year |
Eligible candidates tested |
Passed Number (%) |
Placed Number (%) |
|
1970 |
270 |
77 (28.5) |
77 (1OO) |
|
1971 |
437 |
102 (23.3) |
102 (100) |
|
1972 |
676 |
215 (31.8) |
214 (99.5) |
|
1973 |
957 |
292 (30.5) |
152 (52.0) |
|
1974 |
810 |
358 (44.2) |
262 (73.0) |
returning American medical students who began their
training abroad after failing to gain entrance to an American school.
Fifth pathway
Illinois became involved in the "fifth pathway"
when S.B. 1621 became law (P.A. 78-1240) in 1974 and amended
the state Medical Practice Act. P.A. 78-1240 was designed to enable
Illinoisans who are graduates of foreign medical schools to be licensed
by the state as physicians by entering an Illinois medical school, taking
additional courses, completing an internship and qualifying for the standard
final medical examination upon affidavit that they intend to practice medicine
in Illinois. To entice medical schools to accept such transfer students, the
78th General Assemby voted an appropriation of $60,000 for those medical schools
actively participating in the program. Currently, there are five "fifth pathway"
students in training in Illinois, four at Rush Medical School and one at Loyola School of
Medicine. Dean William Hejna of Rush Medical College states that the preliminary
assessment of the students and program is positive.
Illinois has seven medical schools: Loyola University Stritch School of Medicine, Northwestern University medical School, Rush Medical College, Southern Illinois University School of Medicine, University of Chicago Pritzker School of Medicine, University of Illinois College of Medicine, and University of Health Sciences (formerly Chicago Medical School). The University of Illinois also administers two regional centers at the Rockford School of Medicine and the Peoria School of Medicine.
Northwestern University Medical School designed a special program initially for eight Americans who were enrolled at the Universidad Autonoma de Cluadalajara, Mexico, an institution which trains more American medical students than any U.S. medical school. Since students at Guadalajara do not receive as much clinical preparation in the first two years as their counterparts in the United States, Northwestern developed a special preparatory course in physical diagnosis and clinical correlations for the transferees. The Northwestern program now has 12 students in both the third and the fourth years.
The shortage of third and fourth-year positions is the major problem for transfer students; another is the fact that Americans studying abroad do not do well on the COTRANS examination. Performance on the screening examination indicates that only about 10 per cent of alt American medical students studying abroad would be able to return to a U.S. medical school. Inadequate training appears to be the major reason for the poor performance of the remaining 90 per cent.
Supplemental programs
Reentry could be considerably eased by creating a number of
supplemental training programs especially designed for Americans
studying abroad who wish to return. Upon successful completion of such
a program, candidates would be allowed to join their peers in the physician
training sequence of U.S. medical schools. The University of Colorado
launched such a program, under the auspices of the U.S. Department of Health,
Education and Welfare, in the summer of 1974.
The changes in the Illinois Medical Practice Act effected by P.A. 78-1240 terminate September 1, 1978. Unless new positions for transfer students are created and supplemental training programs are established, little headway will be made in meeting the needs of Americans trained in foreign medical schools or in countering the influx of foreign medical graduates.ž
August 1976/ Illinois Issues/19