Brain drain

Licensure delay provides incentive for IMGs to leave Texas
after residency training

By Monica Kortsha

Cephas Mujuruki, M.D., is the chief-resident-elect at the Texas Tech University Family Medicine Residency Program in Amarillo. He grew up and went to medical school in Zimbabwe. Although he’s only a resident, Mujuruki has an extensive medical résumé: He’s a registered family physician in Zimbabwe, which required completing five years of medical school and a two-year internship that resembled a mini-residency, with four six-month rotations in surgery, internal medicine, pediatrics, and obstetrics/gynecology. After graduation, Mujuruki worked as a family doctor in government and mission hospitals in Zimbabwe and Namibia before moving to Texas in 2008 to enter Texas Tech’s residency program.

He’s lived in Texas for only three years, but has quickly grown to love the state where his 4-month-old son was born. However, Texas law requires international medical graduates, or IMGs, to complete three years of residency before they can receive a medical license, meaning Mujuruki won’t be able to practice in Texas immediately after graduation. This is something he says he and his family cannot afford.

The Texas Legislature is considering a measure supported by TAFP that would remove this licensure barrier for IMGs, but if it’s not passed, Mujuruki, who planned to practice medicine in rural Texas, says he will leave the state and settle somewhere where he can start practicing and earning income right away.

“The welfare of my family has to come first and I would rather take up a full-time job and settle with them than do locum tenens in another state waiting for a Texas license,” Mujuruki says.

Unlike IMGs, residents who graduated from U.S. medical schools can get their license after one year. Not having a license in hand at graduation can trigger a series of delays that prevents an IMG from practicing medicine in Texas for months after residency.

“One of the principles we’re trying to get across is it’s a ripple effect that we think a lot of people aren’t aware of,” says Troy Fiesinger, M.D., clinical associate professor of family medicine at the Memorial Family Medicine Residency Program and TAFP treasurer

To qualify to take their board certification exam, residents must have their medical license. Because IMGs can’t receive a Texas license until after they graduate, they usually don’t have it in time to take the board certification exam in mid-June. Since board certification is usually a requirement for insurance credentialing and hospital privileges, IMGs are essentially out of the job until they can take the next board certification exam in December.

Residents who graduated from a U.S. medical school don’t face the same delays and are able to take their board exams within weeks of residency graduation, which not only increases the speed in which they’re board certified, but also their score on the exam, says Rebecca Gladu, M.D., associate program director of the San Jacinto Methodist Family Medicine Residency Program.

“The residents do the best when they come right out of residency and take that exam,” she says. “It puts [IMGs] at a further disadvantage to have to wait until December to take the exam. That’s a little bit of discrimination here.”

Not having a license until after graduation can take a toll on an IMG’s career even while he or she is still in residency. According to TAFP past president Kaparaboyna Ashok Kumar, M.D., director of medical student education at the University of Texas Health Science Center at San Antonio, hospitals, physicians groups, and other potential employers start recruiting residents at the beginning of the third year and often don’t want to take a chance on a physician who doesn’t have a license.

“You can say all you want to say to them, but they don’t want to look at you because nobody is 100-percent sure that you will get [your license],” Kumar says.

Not being able to line up a job before graduation can create a “catch-22” for IMGs staying in the U.S. with a visa, which requires them to have a job offer immediately after they finish residency to remain in the United States.

To avoid the delay, many IMGs obtain medical licenses in states like New Mexico or Oklahoma that allow them to be licensed before completing residency. Once they’ve finished their training, they have an incentive to leave the state.

Although it’s possible for IMGs to apply for a Texas and an out-of state license, and then use the out- of- state license to take the board exams, many can’t afford the costs associated with two licenses, or don’t want to wait for a Texas license when they can start practicing in another state.

“When you come out of school with $100,000, $150,000 worth of debt, those payments start immediately,” Fiesinger says. “They cannot afford to wait. We’ve had residents who lived barely above the poverty level because they had a family.”

After attending medical school in India and completing his residency in Texas, Kumar became licensed in Oklahoma and practiced there for four years because he was unable to get a Texas license right away. He later returned to Texas to take a position at the residency program where he trained. However, Kumar says that when most IMGs leave Texas, they leave for good, becoming part of their new community.

“We have a brain drain,” Gladu says. “Our trained residents we paid for with our state funds to deliver services in the state of Texas end up leaving Texas because they don’t have their license.”

While moving to a different state may help jump-start IMGs’ careers, it adds to the severe doctor shortage that Texas faces. Half of Texas’ 254 counties are classified as full health professional shortage areas, or HPSAs, having less than one physician per 3,500 people. The numbers are likely to get worse with fewer than 20 percent of U.S. medical school graduates planning to enter primary care, according to the Council on Graduate Medical Education.

IMGs are already an important part of the physician workforce in America; one in four physicians is an IMG. They have great potential to help fill the family doctor shortage in Texas, too, with IMGs increasingly deciding to pursue family medicine residencies over the last decade. They currently make up 38 percent of family medicine residents in Texas. According to the National Residency Matching Program, slightly less than half of family medicine residency spots were filled by U.S. medical graduates in this year’s match.

The logic behind the waiting period in Texas is to give extra time to make sure that IMGs have been educated up to U.S. standards. Residency directors say that U.S. medical graduates and IMGs are held to the same high standards, complete the same rotations, perform the same tasks, and, when their respective application times come, take the same medical licensing exam. Fiesinger says that this equal evaluation should result in equal licensure opportunities.

“It blows my mind that someone comes here on a visa; trains; meets every requirement, every test, and every standard; and then we make them wait. We have the cream of the crop from other countries.”

In some cases, IMGs have more clinical experience than U.S. graduates because of the mandatory clinical rotations or service that many foreign medical schools require.

“These doctors are experienced and mature,” Gladu says. “It hurts me when I know that we’re holding up such great doctors that I would send my own family to.”

When IMGs decide to leave Texas they have plenty of options; 24 states allow them to obtain medical licenses during their first three years of residency training. When IMGs decide to leave Texas they have plenty of options; 24 states allow them to obtain medical licenses during their first three years of residency training.

The bill, House Bill 1380 by Rep. Vicki Truitt, R-Keller, passed out of committee in late March. The Senate Health and Human Services Committee took up its companion, S.B. 1022 by Sen. José Rodríguez, D-El Paso, in April.

According to a TAFP issue brief, found in the Advocacy Resources section of www.tafp.org, passing the legislation is a small change that would have a tremendous effect on Texas’ health care system. IMGs who are practice-ready, Texas-trained, and who would like to remain in Texas are leaving, often because of the unnecessary delays they face. Passing the legislation can help keep primary care physicians in Texas and, in effect, improve access to cost-efficient and high-quality health care across the state, the brief says.

No matter the outcome of the legislation, Mujuruki says he’ll be saving lives as a family physician. But if he it was up to him to decide, he says he would rather be doing it in the “great state of Texas.”