Educated Abroad : Doctors Find Bias in U.S. Over Training

Dr. Rouben Aftandelians, a pediatrician who was graduated from medical school in his native Iran and completed his post-graduate medical training in the United States, encountered an unexpected roadblock when he moved to Maryland in 1986 and sought to practice there.

Although he already was licensed in both California and Pennsylvania, Aftandelians said he was told by Maryland officials that his English was not good enough and that he could not be licensed unless he produced documents from his medical school in Tehran verifying that he had studied there.

Sees Fruitless Pursuit

“I told them that due to the less than friendly relations between our two countries, I doubted I could get my records,” Aftandelians said.

He was correct. Aftandelians, who now serves Navy personnel in an outpatient clinic in San Diego, concluded that Maryland’s requirement was “just a gimmick to exclude foreign nationals.”

“In this day and age, in a country built by immigrants, this is not the time and place to practice something like this,” he said. “I think it’s pretty petty and ugly.”

He is not alone in that opinion. In recent years, a growing number of physicians who were born and educated abroad have complained of inequitable and discriminatory treatment in the United States.

“In the 1960s, America needed medical manpower, and we all came here and were welcomed,” said Dr. Navin Shah, a Maryland urologist born and educated in India. “Now, despite our good records, they are trying to kick us out.”

Shah, who chairs the Alliance of Foreign Medical Graduates, an organization representing about 60,000 foreign-trained physicians, says that 123,000 foreign medical graduates now practice in the United States, nearly 22% of all physicians here.

He cited numerous instances of physicians who, having practiced in this country for years, met frustrating obstacles when they tried to move to a new state or sought new jobs or promotions.

Many foreign-educated physicians, he said, have been flatly told by prospective employers that “we do not hire foreign medical graduates.” Others have been told that they could not head their departments for the same reason. And still others, like Aftandelians, could not get a license in a new state unless they were able to provide information about medical schools in their native lands--information that was either long forgotten or no longer obtainable.

Impossible Demands?

“We are here for the last three decades and now--after 10, 20 or 30 years--if you ask us how many books our libraries had, or how many Ph.D.’s taught us in the biochemistry department, it is impossible for us to get this information,” Shah said. “No information should be asked about (a doctor’s) past medical school in order to make a decision about job, promotion, hospital privileges, licensing and reciprocity.”

State officials, however, insist that such scrutiny is necessary to ensure quality health care, particularly because foreign medical schools are not subject to U.S. accreditation.

“Licensing boards are in business for one thing--and that is to protect the public,” said Dr. Bryant Galusha, executive vice president of the Federation of State Medical Boards of the United States.

“One thing that has been exceedingly troublesome for medical boards is the quality of that undergraduate medical school education--there are many foreign medical schools where you absolutely cannot get an insight into the quality of their education. In this country, at least you know that a student who goes to an American school has been exposed to a high-quality program.”

Others Share View

Galusha’s view is shared by other organized medical organizations, including the Assn. of American Medical Colleges.

“We place a great deal of value on the accreditation process and the assurances that the process gives to the quality of education received by a U.S. graduate,” said Sarah Carr, a legislative analyst with the association. “None of the foreign schools are accredited by any U.S. body.”

Foreign medical graduates seeking to practice in the United States are not permitted to take the national boards, the three-part examination required of all domestic medical school graduates. Instead, to begin training as an intern or resident here, they must first pass an examination called the Foreign Medical Graduate Examination in the Medical Sciences.

In most states, graduates of U.S. medical schools must spend one year--longer in some specialties--in residency, usually at a hospital, before they can become fully licensed doctors. During this period, they practice their specialty under close supervision by fully licensed doctors.

By contrast, graduates of foreign medical schools, even if they are American citizens, must complete at least two, and sometimes three, years of residency, depending on the state where they wish to practice.

Time for Evaluation

“It gives the licensing boards more time to observe the clinical skills of individuals graduating from schools where they have no idea of the quality of education,” Galusha explained.

To obtain licenses after their residency, foreign medical graduates--and even physicians who are licensed to practice overseas--must pass another examination, the Federation Licensing Examination, or FLEX, which has been accepted by all state licensing boards.

Particularly nettlesome to foreign medical graduates are tough--and sometimes impossible--regulations governing when they may move from one state to another. Some states require documents or other information from foreign medical schools, an especially difficult task for physicians who have been in this country for many years. Others also ask applicants to take a spoken English test.

Aftandelians, who had taken his internship and residency in the United States and was already licensed in two states, was told by Maryland that he had failed his English examination. Further, he was not able to produce the necessary documents verifying his 1962 graduation from Tehran University Medical School--not surprising because the United States and Iran have not had formal diplomatic relations since 1980.

Seeks Uniform Treatment

“If a foreign medical graduate has completed . . . the U.S. training and gotten a license in any one state of the country, then that (graduate) should not be treated any differently than the American medical graduate,” Shah said.

“Even though I may have come from a school which is not equivalent in standard to that of the United States, I have taken years of American training and now I am in practice, so judge me on my training and performance, rather than on my medical school background,” Shah added. “One can get a bad doctor from the best school and an excellent doctor from the worst school.”

Shah cites several studies whose findings show no performance differences between U.S. medical graduates and their foreign counterparts. One study of more than 14,000 cases published in March, 1986, in the journal Medical Care states: “The FMGs (foreign medical graduates) provided equal care to the USMGs (United States medical graduates) and sometimes the FMGs provided even marginally better care than the USMGs.”

But Galusha, of the Federation of State Medical Boards, defends the right of states to scrutinize physicians, even those who have been in practice in this country for many years. “The issues here are life and death,” he said, “and responsible authority at the state level . . . is not to be taken lightly.”

He added: “Medical knowledge can indeed deteriorate over time . . . . I don’t think citizens of Maryland would want California setting its practice standards.”

States Tighten Regulations

States have tightened their regulation of foreign-trained doctors, Galusha said, in response to the proliferation of low-quality “entrepreneurial” medical schools, particularly in the Caribbean, to educate the thousands of Americans who have failed to gain acceptance to U.S. medical schools.

“I think the game really changed when U.S. graduates began leaving the country and attending these entrepreneurial schools that just couldn’t be evaluated,” he said.

Reps. Stephen J. Solarz (D-N.Y.) and Jim Bates (D-San Diego) offered legislation this year to standardize requirements for foreign and domestic medical graduates, and Rep. Henry A. Waxman (D-Los Angeles), chairman of the House Energy and Commerce subcommittee on health, later drafted his own bill.

Waxman’s measure would prohibit discrimination against “established licensed physicians.” Qualifying, among others, would be clinicians with at least five years of licensed practice in a state and “no adverse professional review actions” taken against them.

But all the bills drew strong opposition from organized medicine, including the American Medical Assn., which said that the legislation represented an intrusion into what has traditionally been the province of the states. The bills were withdrawn, pending a study of state licensing practices and policies by the congressional General Accounting Office.

While the AMA believes that licensing falls within the jurisdiction of the states, it has not ignored the plight of foreign medical graduates. An ad hoc AMA committee on foreign medical graduates earlier this year polled nearly 2,000 of its members, including U.S. medical graduates, U.S. citizens who graduated from foreign schools and foreign-born physicians who graduated from foreign schools.

Most U.S. Doctors Favor Curbs

The results were not surprising. More than 90% of the U.S. doctors said that they favored restricting the number of foreign medical graduates who were granted medical licenses, while more than 85% of the foreign-born graduates favored equalizing the licensing requirements for everyone.

Although all three groups acknowledged that there is discrimination against foreign doctors, foreign-born and foreign-educated medical graduates were more likely to notice it. They said that the most common reason, however, was not educational credentials but racial or ethnic background.

“No system . . . can be perfect,” Galusha conceded. But he said that he believes the current process is fair.

“There are about 120,000 foreign medical graduates practicing in the United States representing 21.6% of practicing physicians in this country,” he said. “The foreign medical graduate is playing a very dominant role in American medicine. If we are indeed discriminating, we’re doing an abominably poor job of it.”