Last week the Tennessee State Legislature passed HB 1312 and yesterday it was signed into law by Gov. Bill Lee.
HB1312 allows IMGs/FMGs who have passed all 4 USMLEs, who have completed a accredited medical residency outside of the United States/Canada or have legally practiced medicine (I.e. held a valid medical license for the country they worked in) for at least 3 of the past 5 years to obtain a provisional medical license in Tennessee.
Provisional license holders must complete 2 years of supervised practice at a Tennessee hospital that hosts an accredited residency program [in their specialty] before they will be granted a full, unrestricted medical license.
Applicants for the provisional license must be US citizen or permanent residents or be legal visa holders who are eligible for permanent residency.
This is bad, bad news. The standard of medical education varies widely across the world. Many, many FMGs arrive for US residency with very poor education, with tremendous gaps and deficiencies. Being able to pass the licencing exams does not mean you are ready to practice. It is not unusual for first year US residents, given a dry run of the specialty certification exams (beyond licensing exams), to pass, only two weeks after they start their internship year - I did, but I still had to do 3 years of residency!
In addition, acceptance to medical school (invariably only 6 yrs, vs 4+4 for US) in many 3rd world countries is via bribes and influence. Being able to demonstrate hands on competency in a US residency program is a way of ensuring that incompetent FMGs dont slip through.
I think the hazard factor is likely proportional to what exactly happens in those two years. Like Parentologist, I think incoming folks will vary widely from one another in their skill sets, experience, and general suitability. I do worry about language barriers as well.
It begs the question of why Tennessee wonât invest in additional medical school and residency spots in their state. Maybe to keep taxes low. Well then I hope âtheyâ donât complain about people who donât look and talk like them showing up in their communitiesâŠ
Itâs very unlikely though that there is a strong foreign lobby advocating for this though. So, someone must be for some reason. I suspect they have a severe provider shortage and had to resort to âitâs better than nothingâ as a fix. Not sure though. The whole thing is a bag of snakes.
I would imagine that the University of Tennessee (state-controlled) would take the initiating step in requesting accreditation of additional training spots but I could be wrong. Public hospitals, same thing. Local action first, then federal permission as needed? Again, I could be mistaken.
Medical schools are regulated at a national level by the LCME, an independent accrediting agency, for all MD med schools and by COCA , a different independent accrediting agency, for all DO schools.
Residency programs are accredited by ACGME, another independent national accrediting agency. However, the bulk of residency positions are funded by the federal government through Medicare. The rest of the funding to support residency programs comes from either the hospital itself or state funds.
HCA Healthcare, a for-profit chain of hospitals and clinics that is headquartered in Nashville, is the most likely driver behind the bill. HCA has discovered that opening residency programs in its hospitals makes good fiscal sense: residents generate billable services at much lower cost-to-the-company than attending physicians since the most of their costs (for salary, benefits, malpractice) are paid for by the federal government.
HCA is known for rapidly expanding the number of emergency medicine residencies at its hospitals, many of which do a poor job of educating its EM residents. (Residents at several of its programs are âgraduatingâ without doing a sufficient number or diversity of procedures to qualify for board eligibility in EM.)
There are now more EM physicians in the US than there are available jobs.
As I suspected, itâs to combat provider shortage.
And, it looks like they have some built in safeguards to ensure that there is a level of competence in the physicians they let in.
From STAT:
âTo ensure only highly qualified doctors use this pathway, the law requires international doctors to demonstrate equivalent training, pass the same exams, be fully licensed in good standing in another country, and have practiced medicine abroad without incident. Furthermore, doctors have to be sponsored and employed by a health care provider that also trains residents. After two years of successful and safe practice, this law automatically grants these doctors a full Tennessee medical license. The only thing this law doesnât require: repeating a three-year or longer residency training program.â
I have seen a med school graduate coming from Egypt starting an internal med residency at a big inner city hospital (good teaching site for med students, not a desirable internal med residency site) ask the US med student to teach the FMG how to do a history and physical - the first thing we learn at the end of 2nd year, before we go out to start med school rotations. I have seen many Eastern European residents (in the era right around the fall of the Iron Curtain) who had very different training, had been taught to diagnose normal conditions as disease (hydrocephalus in normal infants), didnât have a basic foundational understanding of pathophysiology.
On the other hand, the South African trained docs ran circles around us, they were SO good, so much better than us Americans.
The states get to be in charge of licensing standards in their own state. If they wanted to, they could license people right out of med school, not that any insurance company would credential and pay them, and most hospitals would not give them privileges.
Requiring that FMGs do a residency insures that they meet the lowest common denominator standards of US med training. Foreign docs who do 6 yrs instead of 8, who may have bribed their way into med schools in their countries which are famous for graft and corruption, and then no standardized training program here? What could go wrong?
USMLEs only test basic medical knowledge (pharmacology, immunology, biochemistry, genetics, etc). USMLEs are necessary intermediary steps toward further training and not a final evaluation of physician competency.
Not sure why you think 2 extra years of general education requiments in college would yield better doctors. No other countries think so; hence the 6 year requirement instead of our 8 year slog.
Plenty of American-trained medical doctors who passed US residency on not all that competent, and the US over relies on doctors for illnesses easily treated by nurses, np, paâs or other health professionals in other couuntries. Given an aging population and a shortage of providers, this might be a solution. Why would an experienced European doctor be unqualified to work here?
I donât see American medical doctors providing any solution to the current shortage, which is likely to worsen.
The US baby boomers are roughly 60-77 in age now. We have had 60 years to address the predictable need for increased medical care, and thus medical care providers, for this cohort. If we have failed to do so, we should expect creative solutions.
Itâs not experienced European doctors who want to come here. Itâs 3rd world doctors. How many of your doctors are from Scandinavia? How many from Pakistan, India, Egypt?
The appropriate role for NPs and PAs is for use as technicians, performing the same procedure (colonoscopy, bone marrow biopsy, and such) over and over. This doesnât require algorithmic thinking relying upon an enormous foundation of preclinical knowledge and a minimum of 5 years of 80 hr/week clinical training with patients (last 2 yrs of med school, plus at least 3 yrs of residency). During this time a doctor in training sees tons and tons of patients, tons and tons of presentations of illness, so that you learn to recognize the one pneumonia in the sea of colds with coughs, the one pulmonary embolus in the sea of respiratory illnesses, the heart attack in the young thin man in whom youâd never have suspected it, the ear canal cancer that came in as a purported external ear infection, the young man with herpes eye infection instead of simple conjunctivitis, the bad headache thatâs really a stroke, heck the stroke in the new mother who isnât even your patient who has slight facial asymetry when she brings in her baby - the list just goes on and on. The way you learn to recognize these things is through intense training in the last two years of med school and residency, when you spend literally 4,000 hours a year for at least 5 years - thatâs a minimum of 20,000 hours in direct patient care, where you see and hear about not only your patients, but all the other patients on your teams.
You donât get this very necessary training in the path that leads to NP or PA. You donât get the same standard of training in most other countries (except South Africa, which was in the past better than us, but I donât think this has been the case for probably 30 years now). There was a very good reason that we had a hard and fast rule about having to do a residency in the US. What TN is proposing is not the equivalent of residency training in the US, will license FMGs who are inadequately trained in US standard of care medicine.
We can complain all we want, but TN is progressively going into the negative on provider coverage. Since no one to date has offered an alternative, they probably figured a weak provider is better than no provider.
It is quite possible the foreign doctor will not be weak. Americans do not have the monopoly on talented doctors. Europe, Israel, Japan, Australia and yes India all have some very highly regarded doctors.
Donât think for a minute that US doctors havenât played a role in keeping MD supply low in the US. Supply and demand. Keep wages high. My wife fights this whenever she tries to expand scope of coverage at her hospital. It always comes back to lower reimbursements. This is just one of the results.
Similar happening in anesthesia. New programs offering MS in Anesthesia. No medical background required. At least as a CRNA my wife was an ER/CC nurse for a few years. Trial by fire. Invaluable experience. Not sure how these people will react under stress.
We essentially had socialized medicine available when I was younger. The coal mining union built clinics in rural areas. Free for mining families. The drawbacks were you might walk-in when they opened and not get home until dinner. Also, most doctors were foreign. Not saying they were bad but unsure of their certifications and qualifications.
