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WASHINGTON -- Are there too many foreign-born physicians working in the U.S., or not enough? Members of one House subcommittee appear to be strongly divided on the issue.

"Today, approximately 200,000 foreign medical graduates work as physicians in the United States," Rep. Jerrold Nadler (D-N.Y.), chairman of the House Judiciary Committee, said Tuesday at a held by the committee's Subcommittee on Immigration and Citizenship. "Immigrants account for more than 50% of physicians practicing geriatric medicine, approximately 40% of those practicing critical care and internal medicine, and nearly one-quarter of those practicing general medicine."

Shortage Is Getting Worse

Even before the COVID-19 pandemic, the Association of American Medical Colleges (AAMC) had already projected a shortage of nearly 140,000 physicians by 2033, Nadler continued. But now, "the pandemic has taken an enormous mental and physical toll on physicians in the United States, exacerbating existing shortages and making these projections even more dire."

Many states are struggling to meet demands for care, "but unfortunately, our outdated immigration system only adds to the problem," he concluded. "We must ensure that our immigration system facilitates -- rather than blocks -- the admission of the best doctors from around the world."

Not so fast, said Rep. Tom McClintock (R-Calif.), the subcommittee's ranking member. Democrats seem to want more foreigners to enter the country, "and they have yet to explain how our hospitals are made more accessible by packing emergency rooms with illegal aliens demanding care," he said. "Instead, their solution is to import still more foreign doctors to treat the exploding foreign population. Enough!"

"There are thousands of U.S. citizens who have earned their medical degrees at enormous cost ... but they cannot be placed in residency programs that make it possible for them to practice medicine," McClintock said. "Furthermore, foreign nationals are already admitted to practice medicine in this country through a large number of visa programs."

"The physician shortage in the United States is largely of our making," he added. "We have the doctors. We just don't match them with the residency programs they need to enter practice. Now, don't you think that just maybe we ought to put American physicians first?"

Contributing Factors

AAMC president and CEO David Skorton, MD, listed five factors that are contributing to the physician shortage in the U.S.:

• A growing population.
• An aging population. "And with age will come the necessity of greater need for healthcare," Skorton said.
• An aging healthcare workforce. "At a certain point, like every other kind of worker, the medical workers over 65 will decide to retire," he said. "And because of the big hump of humanity in the [Baby] Boomers, we're seeing more retirement."
• A lack of graduate medical education (GME) residency slots. "The fact that we've increased the number of slots for first-year medical students by over a third is not enough to make a difference because of the need for graduate medical education slots," said Skorton. "And we're still not getting the job done."
• COVID-19 and its stresses on the healthcare workforce. "We have lost people to COVID; we have lost people to behavioral health problems -- even suicide -- related to the stresses of COVID," he said. The pandemic also "has led to some physicians deciding that they wanted to retire earlier than planned, or if not retire, to perhaps reduce their hours."

Kristen Harris, an immigration attorney in Chicago, recommended several steps Congress could take to allow more foreign physicians to practice in the U.S., including expansion of the , which allows foreign medical graduates with a J-1 status to stay in the U.S. for 3 years if they treat patients in a medically underserved area. "Each state is allotted only 30 waivers per year, a limit that was last raised in 2002," Harris said. "The program has successfully brought thousands of U.S.-trained physicians to medically underserved communities, but it can do more if it were expanded and improved."

J-waiver options also need to be improved for federal agencies such as the Department of Veterans Affairs and the Department of Health and Human Services, Harris said. "My firm represents nephrology practices, including a practice that continues to find U.S.-trained J-1 physicians who are ready, willing, and able to start treating dialysis patients, but for their need for a J-waiver. They haven't been able to do that. Any one such nephrologist can cover 13 practice sites stretched across a five-county area ... Unique patient visits from one physician can exceed 200 patients in a month."

In addition, "the employment-based green card system needs to be fixed to keep our U.S.-trained doctors in the country on a permanent basis," she said. "Doctors born in India can wait for over a decade before they're permitted to even file their final step for a green card due to current per-country limits, even when their services to the medically underserved have been deemed to be in the national interest ... This is wrong. These physicians fill an immediate need for Americans and therefore should be permitted to file for a green card immediately."

Are U.S. Doctors Being Displaced?

Kevin Lynn, co-founder of Doctors Without Jobs, a group aimed at prioritizing U.S. citizens for medical residencies, said he was "gobsmacked" by the current situation. "Prior to 1980, there was a situation that existed where we weren't filling the residencies available," he said. "So you could see where at that point, there would be some mechanism to help fill that with foreign-trained physicians, and we did. However, that is not the case today." Instead, "there are thousands of doctors every year who are U.S. citizens, or are lawful permanent residents, that are not getting residency positions ... I don't see a need at this point to continue on with the number of foreign-trained physicians. We have the doctors right here in the U.S."

The remarks by Lynn, who is also executive director of , contrasted with statistics Skorton gave in his opening statement. "Last year 55% of non-U.S. graduates of international medical schools matched to a residency program," said Skorton. "Comparatively, 93% of U.S. seniors match to a residency program, and 99% of U.S. medical school graduates enter residency or full-time practice within 6 years. I can confidently say that physicians from other countries are not displacing graduates of U.S. medical schools."

Rep. Ken Buck (R-Colo.) suggested that Skorton had his emphasis in the wrong place. "I think that -- perhaps because of a liberal bias, perhaps because of other factors -- you've really understated some of the other issues that exist," he said. Buck asked Skorton what percentage of foreign doctors who come into this country and "receive a tax-subsidized education" end up working in underserved areas for 5 or 10 years.

Skorton said he didn't know but would get back to Buck quickly. He offered to work with subcommittee staff members and Lynn "so we can reconcile very different numbers that you're hearing -- so that we can give you something that you can hang your hat on."

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