Building Strength in Cultural Care

Recruiting Refugee Physicians

Overview: Minnesota’s population is increasingly diverse, a change that results from both refugee resettlement and migration, legal and otherwise. A growing number of Minnesota health care patients bring with them an understanding of medical practices and customs developed in Central and South America, East Africa or Asia.

Training providers in culturally competent care is one route toward bridging the gap between the expectations of providers and patients, and toward more effectively meeting patient needs. However, a body of research also shows that outcomes improve when there is concordance between the race and ethnicity of provider and patient. Further, cultural-care training and practice are enhanced when students and providers bring with them diverse experiences and life history. Refugee physicians — doctors trained and practicing in their own countries before being displaced by political turmoil — are a valuable resource in the effort to serve Minnesota’s diverse patient base.

Substantial barriers often block the path of refugee doctors who seek to practice medicine in the United States. Language issues, the cost of testing to achieve licensure, the complex culture of American medical practice and the difficulty of securing a residency position are among the reasons refugee physicians often remain underemployed in non-medical jobs. The subsequent frustration for the refugee physician and sub-optimal medical treatment for his or her fellow refugees could be ameliorated by programs that help ease the passage of refugee physicians into practice.

A Changing State Population

New waves of immigration and a changing patient base

Successive waves of immigration have changed Minnesota’s complexion markedly since the late 1970s. The end of the war in Vietnam brought refugees from Vietnam, Laos and Cambodia. The fall of the Soviet Union in 1991 resulted in an increase in arrivals from Eastern Europe. Refugees from Bosnia-Herzegovina were followed by people fleeing from Somalia. During the same period, non-refugee immigrants from India, China and Pakistan arrived to work in high-tech fields. Latinos came and in many cases took work in meat, poultry and food processing plants.

The exact number of these refugees and immigrants is notoriously difficult to estimate. Initial refugee arrivals are tracked, but not secondary migrations of refugees who move to join family members or to seek better opportunities. Illegal immigration, of course, is also undocumented. The state demographer’s best estimate in 2004 put the state population of recent immigrants at about 325,000, with Latinos (175,000), Hmong (60,000), Somalis (25,000) and Vietnamese (25,000) ranked as most numerous. These numbers, based on the primary language Minnesota school children speak in the home, are by now understated. For example, using the primary language formula, the number of Somalis in Minnesota is now more likely about 40,000.

(1. Estimates of Selected Immigrant Populations in Minnesota, Minnesota State Demographic Center)

(2. Dataset, Office of the State Demographer, June 11, 2009, http://www.demography.state.mn.us/a2z.html/#Refugees

Where Minnesota Physicians Come From

Fewer foreign-born physicians than the national average

Compared to the national average, Minnesota has a low number of foreign trained doctors. For recent immigrants and refugees, the odds of being treated by a physician who truly understands their language and cultural milieu are remarkably slim.

Four out of five of Minnesota’s 19,414 physicians are born in the United States, according to data from the Minnesota Board of Medical Practice. Slightly over 15 percent are international medical school graduates — compared to a rate of 26 percent in the country as a whole. (3. American Medical Association: International Medical Graduates in the US Workforce)

The largest numbers of Minnesota 3,645 foreign-born doctors come from India (672), with significant numbers from Canada (397), Pakistan (195), Germany (157), China (115) and the United Kingdom (102). The match-up between birth place of Minnesota physicians and numbers of recent immigrants is weak. For instance, there are 14 Minnesota physicians who were born in Somalia. That translates to one Somali-born doctor per 2,857 Somali residents of Minnesota, assuming a Somali population of 40,000. (4. Dataset, Minnesota physicians, Minnesota Board of Medical Practice, August 20, 2009)

About two-thirds of Minnesota’s 1,376 resident physicians are US medical school graduates, while 32 percent graduated from international medical schools. Fifty-five percent of Minnesota medical residents were born in the US, while 45 percent were born in 87 different countries. Leading countries of birth for Minnesota residents are India (128), Pakistan (35), Canada (22), Colombia (15), China (14), Germany (13), Peru (11), Iran (10), Phillipines (10), South Korea (10) and Thailand (10). Three were born in Somalia, five in Russian and six in Ethiopia. (5. Dataset, Minnesota physicians, Minnesota Board of Medical Practice, August 20, 2009)

Minnesota is also home to a number of physicians who were trained and in practice in their own countries, but who have, for a variety of reasons, been unable to become licensed in the US. The St. Paul-based African and American Friendship Association for Cooperation and Development (AAFACD) has found and tracked 133 such physicians. Thirty-five of these doctors are refugees or asylees. Twenty eight of the total number are from Somalia. Another 14 are from Sudan, and seven from Ethiopia. Should they navigate their way through medical licensing exams and successfully complete a residency that would allow them to practice in the US, these doctors would bring valuable knowledge and perspective to the treatment of recent immigrants and refugees.

But in the US, refugees have had scant success gaining access to residency programs. According to a tally by the American Medical Association’s International Medical Graduate Governing Council, 99 of the country’s 106,012 residents are refugees, asylees or displaced persons. (See 3, above.)

Why It Matters: Patient/Doctor Racial Concordance

Research suggests better compliance, satisfaction, outcomes when there is a match

A by-now extensive body of research establishes that patients are more satisfied and in some instances receive better care when there is concordance between the race or ethnicity of the provider and patient. Several cases in point:

• In a national study of HIV-positive patients and their physicians, African-American patients with white doctors received protease inhibitors significantly later in treatment than African-American patients with African-American doctors — 461 days vs. 342 days. “Our study indicates that race concordance influences the delivery of state-of-the-art care,” the researchers observed, adding, “Patients often select providers based upon specific characteristics, including race and ethnicity. African-American patients should have access to a provider of their own race and ethnicity if they so choose.” The same argument could be made for Somali, Bosnian, Russian, Vietnamese and other refugee patients in Minnesota. (See: 6. Does Racial Concordance Between HIV-Positive Patients and Their Physicians Affect the Time to Receipt of Protease Inhibitors?)
• A study of New York City HIV patients and providers found that racial concordance is associated with lower mistrust of the health care system. “It is possible that patients believe that providers who are racially/ethnically concordant can understand and discuss fears of being mistreated by others in the health care system, and this empowers patients to address these fears with a member of the health care system,” the authors reasoned. (7. Does Patient-Provider Racial/Ethnic Concordance Influence Ratings of Trust in People with HIV Infection?)
• A national study of African-American, White, Hispanic and Asian American patients found that in instances of patient/provider racial concordance, patients were:
• More likely to use needed health service
• Less likely to postpone needed treatment
• More likely to report more use of medical services

A related study by the same authors found greater satisfaction with racially concordant providers among African Americans, whites, Hispanics and Asian American patients. (8. The Association of Doctor-Patient Race Concordance with Health Services Utilization, and, 9. Is Doctor-Patient Race Concordance Association with Greater Satisfaction with Care?)

• African American patients with African American physicians are more satisfied with their treatment, have significantly longer office visits with their doctors, and have visits characterized by more patient-positive communication from doctors. “Increasing ethnic diversity among physicians may be the most direct strategy to improve health care experiences for members of ethnic minority groups,” the authors concluded. (10. Patient-Centered Communication, Ratings of Care, and Concordance of Patient and Physician Race)
• In a review of literature from 1966-2000 on the influence of racial concordance on the quality of the doctor/patient relationship, the authors conclude: “Minority patients, especially those not proficient in English, are less likely to engender empathic responses from physicians, less likely to establish rapport with physicians, less likely to receive sufficient information, and less likely to be encouraged to participate in medical decision making. These characteristics have all been linked to patient satisfaction, patient compliance and care outcomes in the general literature on the doctor-patient relationship… There is considerable evidence that African Americans and Hispanics desire and obtain more care from African American and Hispanic physicians, respectively.” (11. Culture, Language and the Doctor-Patient Relationship)

To Practice Medicine in the US

For refugee doctors, an often difficult and expensive process

Like all graduates from foreign medical schools, refugee doctors must establish the legitimacy of their medical education, pass required exams and successfully serve as residents in training programs before being licensed to practice medicine. Briefly, these steps are as follows:

• Confirm eligibility with the Educational Commission for Foreign Medical Graduates (ECFMG), which determines whether international medical graduates (IMGs) are prepared to enter a residency program. The ECFMG assesses whether the IMG possesses a degree from an approved medical program, a valid visa and speaks/understands English adequately. The ECFMG issues applicants a registration number, allowing them to take United States Medical License Exams.
• Medical license exams include:
• Step 1 — measuring understanding of scientific knowledge basic to the practice of medicine (Cost: $660)
• Step 2 — determining if applicants can apply medical knowledge and understanding of clinical science necessary to provide patient care under supervision. (Cost: $660)
• Clinical Skills Assessment — assessing whether IMGs are capable of communicating and conducting clinical exams. (Cost: $1200)
• IMGs who have passed the licensing tests become eligible for residency programs. They apply for residency through the National Residency Matching Program, a computerized system that matches IMGs’ top preferences for residency programs against a list of top candidates chosen by residency program directors. (Cost: $275) (Further details on this process appear in the American Medical Association’s publication, 3. International Medical Graduates in the US Workforce: A Discussion Paper)

Each year roughly 31,000 applicants compete for the 24,000 available residency positions. For IMGs who are not US citizens, the odds against obtaining a residency slot are substantial. A 2003 analysis showed that of 7,576 would-be doctors with ECFMG certificates who were not US citizens, only 2,233 (29.5 percent) secured a residency. (12. The International Medical Graduate Pipeline: Recent Trends in Certification and Residency Training)

Barriers to Residency for Refugee Doctors

Poverty, language, discrimination are among the obstacles

Refugee doctors confront numerous obstacles on the path toward becoming licensed to practice medicine in the US. Frequently impoverished in their flight from political oppression, they may also struggle with employment and transportation issues, emotional trauma and language difficulties. In a 2005 study of refugee health professionals conducted by St. Paul’s African American Friendship Association for Cooperation and Development, these were among the barriers identified:

• Lack of access to information from foreign colleges that is required by accreditation bodies. Often information is held hostage by governments that are hostile to those who have fled for fear of persecution.
• Difficulty navigating the complex testing/certification/licensure process
• High testing costs
• The need for coaching, advocacy, family and peer support

(13. Needs Assessment of Foreign-Trained Healthcare Professionals in Minnesota)

Unlike US medical graduates, who can receive recommendations to residency programs from medical school faculty, refugees are often unknown and disconnected from any helpful professional network. By the admission of surgical residency directors surveyed in a 2002 study, they are also victims of discrimination. Almost half of surveyed residency directors acknowledged that their programs prefer US medical graduates to IMGs because they believe the Residency Review Committee will view their program as weak if it cannot recruit US medical graduates. More than half said their program purposefully avoids matching with IMGs. (14. The Unkindest Cut of All: Are International Medical School Graduates Subjected to Discrimination by General Surgery Residency Programs?)

Several brief, first-person accounts by IMGs who have landed residency positions examine in personal terms the sense of dislocation experienced by those fortunate enough to find placement. Confusion with US slang, the absence of helpful coaching or mentoring, the wide difference in interactions between supervising physicians and residents in the US and countries such as India are among the issues explored. (15. The Role of International Medical Graduates in the Future of Palliative Care; 16. Disorientation; 17. Coming to America — International Medical Graduates in the United States)

Providing Help

A sample of programs that push IMGs toward success

Recognizing the difficulty that IMGs can have adapting to US medical practice and culture during their residencies, several institutions have created programs intended to ease the path of applicants and residents.

Some are pre-courses for IMGs about to start their residencies, such as a program at Creighton University (decribed in 18. An Acculturization Curriculum: Orienting Medical Graduates to an Internal Medicine Residency Program). The mandatory, two-week, unpaid program stresses skills that faculty typically viewed as lacking in IMGs, and included gynecologic exams, writing outpatient prescriptions, EKG interpretation, writing orders for fluids, communication skills with patients and nurses, and lack of verbal participation during rounds.

A different model is presented by the University of Washington Department of Surgery (as described in 19. A Program for Successful Integration of International Medical Graduates (IMGs) into US Surgical Residency Training). This eight-week, student-paid course for IMGs provides a formal, clinical experience “with duties, responsibilities and evaluations similar to fourth-year medical students.” The program provides students with a final score, an assessment of their ability to succeed in the UW residency program, and a letter of reference from the residency program director if the graduate intends to leave UW. Top candidates are offered a two-year position in the program. (A further description of the need for such programs is provided by the authors in 20. Selecting International Medical Graduates (IMGs) for Training in US Surgical Residencies.)

The American Medical Association’s IMG section has produced a package for doctors or administrators who want to create an IMG observership program within their institution. It includes guidelines on responsibilities and eligibility, an organizational model, meeting HIPPA standards, sample letters to administrators requesting permission to start such a program, informational letters to would-be applicants, and an evaluation form. (21. American Medical Association Observership Program Guidelines). This guide has recently been adapted by the Oklahoma State Medical Society and by the Baylor College of Medicine to establish observership programs.

Another example of assistance offered to IMGs is an exhaustive, 88-page booklet (22. A Resource Guide for Internationally Educated Medical Graduates: Information to help you plan your career in Manitoba) produced by the Manitoba provincial government that directs IMGs to language assistance, settlement aid, bureaucratic and educational requirements, testing, educational support, and career alternatives, among other topics.

Summary

Helping refugee doctors return to practice can offer widespread benefits

The personal toll of political persecution on refugee doctors is tragic in a sense shared by all refugees. They have been torn out of their lives and forced to remake themselves in a strange land. For refugee doctors the tragedy is compounded by the loss of their vocation, which they studied and worked years to achieve. Becoming licensed to practice again in the US is an expensive, long and difficult process, attended by numerous cultural complexities.

But refugee doctors also arrive with strengths that make them uniquely qualified to provide quality care to distinct populations, and to improve overall quality of care within institutions. No one is likely to understand the medical and cultural issues of Somali refugees better than a Somali doctor. In addition, institutions with a Somali, Ethiopian, Russian or Vietnamese doctor on staff have a ready resource that cannot help but increase their ability to provide culturally competent care and training. Research shows that patients receiving racially/ethnically concordant care are likely to be more satisfied, more trusting of the medical system as a whole, and in some cases more likely to receive appropriate treatment.

In consideration of the substantial barriers to returning refugee doctors to practice, we are proceeding with an investigation of the hurdles that keep refugee doctors from residency slots. We also suggest that more examination is needed of methods to increase the odds of success in residency programs for refugee physicians.