Immigrant physicians: A solution to workforce shortages?

This story has been updated.

In 2011, Mark Costa moved to the U.S. from his native Brazil with his wife and two children. He had always wanted to experience life in America, his mother’s home country.

Costa, who now lives in Hamden, worked for nearly two decades as a psychiatrist in Brazil and wanted to continue his career. He knew it wouldn’t be easy: Working physicians from other countries must pass all the necessary medical licensing exams and also complete a three-year U.S. residency program, despite having already done residency training in another country.

But the process was more difficult than Costa expected, and he hit barriers that many immigrant physicians face. Some believe these doctors could help solve the chronic workforce shortages that plague the health care system if only there were a way to get more of them into practice.

When Costa began applying for U.S. residency programs, for example, he was stunned to find that he wasn’t even getting invited to interviews. It felt as if, as a fully working physician from another country, he was less appealing than someone coming straight out of medical school.

“It’s a little bit humiliating, because I’m so proud, because I have all this experience. I’m ready to help,” said Costa. “My training in Brazil actually made me less of a candidate.”

He believes it was likely because his medical degree was from several years prior and his letters of recommendation were from Brazil, which can be seen as less valuable than those from the U.S.

Prior to the pandemic, roughly 270,000 college-educated immigrants with international health-related degrees in the U.S. were either working below their level of training or not working at all, according to the Migration Policy Institute .

As the likelihood of acceptance to a residency program waned, Costa needed to find work to support his family. He opted to complete a postdoctoral program in the psychiatry department at Yale University’s School of Medicine, which enabled him to become a research scientist, where he studies mental health disorders, health disparities and substance use disorder.

But, without completing a U.S.-based residency, he had to give up treating patients directly, which he misses.

“You’re focusing on what’s unique to that individual and addressing their issues in the best way possible,” said Costa. “This is what I miss in the clinical work. Connecting with one individual and helping one individual with their needs.”

For years, the health care industry has lobbied the federal government to improve the immigration system so that internationally educated and trained workers could help address workforce shortages. But while the federal government controls immigration policy, some states are looking to tap into the talent of immigrant physicians through a lever they can control: medical licensing.

The challenges of visas and residencies

Connecticut, like the rest of the country, is in the midst of a health care workforce shortage that’s only projected to worsen.

By one estimate , the United States will have 139,000 fewer doctors than it needs by the year 2030. Patients already report waiting months for appointments. The aging population will increase the demand for medical services, while pending retirements threaten to squeeze the supply of health care professionals.

Under the current system, it’s difficult for internationally educated and trained physicians to help ease the health care workforce shortage here. The two biggest barriers to practicing in the U.S. are visas and licensing. Visas, which give non-citizens permission to be in the country, are controlled by the federal government. Licensing, which controls a doctor’s ability to practice medicine, is controlled by states.

With federal immigration policy at a stalemate, a handful of states are addressing the physician shortage by amending their licensing requirements to allow more internationally trained doctors to practice medicine.

Last year, Tennessee passed a law , which went into effect this month, giving provisional licenses to internationally trained physicians without requiring them to repeat residency training. Applicants must pass U.S. medical exams, demonstrate English fluency and provide proof of a medical license in good standing from another country. After two years, they become eligible for a standard license. The law requires applicants already have permission to be in the U.S.

“There is a shortage of physicians in the U.S. There is a need,” said Costa. “If [international physicians] show that they are qualified to do this, respecting all the ethical and clinical training that we need to practice medicine in the United States, it makes sense that there’s some flexibility.”

Several other states have followed suit , passing similar measures to eliminate the residency requirement under certain conditions, including Illinois, Florida and Virginia . Other states, including Alabama and Colorado, have passed laws to shorten residency requirements for internationally trained physicians from three years down to two years and one year, respectively.

Khuram Ghumman, a family medicine physician in East Granby, said he believes some amount of residency training should be required as a way for people to get acclimated to the particularities of the U.S. medical system, like dealing with insurance companies. But he thinks shortening the duration for international physicians with years of experience could make sense.

“No matter where you were trained, going through that U.S. [Accreditation Council for Graduate Medical Education]-accredited program is influential, it’s essential, it’s important,” said Ghumman, who completed medical school in his native Pakistan before coming to the U.S. to do residency training. “But modifying the duration, I think, is a fair compromise.”

Ghumman said that he believes the primary focus should be on retaining physicians who study at international medical schools and come to the U.S. to complete their residency training. But the complexity of the visa process makes granting more people the right to stay here difficult.

There’s what’s known as a J-1 visa, used by most graduates from international medical schools who come to the U.S. to complete their residency. However, that comes with a mandate that physicians return to their home country for at least two years after completing residency training here.

There’s also an H1-B visa, which has no home residency requirement but is tied to a specific employer. As a result, physicians can only remain in the country as long as they work for that employer or find another one willing to sponsor them. The federal government caps the total annual number of H1-B visas, though nonprofit teaching hospitals are exempt from the cap.

“It’s a complicated web,” said Ghumman of the visa process.

One of the most prominent federal programs to allow more internationally educated physicians into the U.S. is the Conrad 30 Waiver Program , which waives the two-year home residency requirement and allows physicians who finish their residency training to stay in the country if they agree to practice in underserved areas. Each state gets just 30 waivers.

In 2023, Connecticut received 42 applications for 30 waiver slots, according to a spokesperson with the Department of Public Health.

“That program needs to be reevaluated and expanded upon,” said Ghumman, who himself stayed in the U.S. after residency through a Conrad 30 waiver. “Even if the state of Connecticut wants to keep those hundreds of international medical graduates who come to Connecticut for their training, they have to leave because they just can’t keep them here.”

Bristol Hospital CEO Kurt Barwis said that he also believes a primary focus for state governments should be pushing the federal government to expand programs like Conrad 30.

“We recruit extensively through the J-1 waiver program,” said Barwis, who estimates Bristol has recruited over 30 physicians under Conrad 30 waivers during his 18-year tenure at the hospital.

The program requires that physicians sign contracts to stay at a hospital for at least three years, with the opportunity to renew for another two, explained Barwis. This, he said, makes these physicians particularly attractive recruits.

“Once they set up their home and they stay for three to five years, they’re going to stay, and they’re going to be a part of the community,” said Barwis. “So we’ve had very little turnover.”

But when it comes to passing laws to remove residency training requirements, as Tennessee and others have done, Barwis is less convinced, saying that he’s concerned about maintaining quality of care.

“Technology, equipment, the most advanced evidence-based practice of medicine may not be available in the country they practice in,” said Barwis. “If you’re not going through that full residency or fellowship, are you getting exposed to it all?”

However, Barwis said he’s heard of people, like Costa, who have run into roadblocks trying to secure a residency position and agrees that those pathways should be improved for people who want to pursue them.

Public Health Committee co-chair Rep. Cristin McCarthy Vahey, D-Fairfield, said she’s open to the measures other states have put in place, but quality must remain the No. 1 priority.

“It seems to me, just given the demographics of our population and the workforce issues we face, that it makes sense for us to explore some options to help address those barriers,” she said.

Sen. Saud Anwar, D-South Windsor, who is McCarthy Vahey’s co-chair and a practicing physician, said that his priority to address workforce shortages is to find work in the industry for U.S. medical school graduates who do not get matched to a residency program.

“If you do not get selected into a residency program, you should still be able to work and help out,” said Anwar, who feels this should be the initial step in addressing workforce shortages. “After that, we can look at other options.”

Potential benefits to patients

Some supporters of efforts to expand pathways for international physicians to practice in the U.S. also point to the opportunity to provide culturally competent care to the immigrant patient population.

“It is very challenging for you to talk about mental health problems, emotional problems, in a different language. Even for me, [and] I’ve been in the U.S. for 13 years,” said Costa. “I would rather have services in Portuguese, because it’s my primary language. But you cannot find those services.”

Costa’s wife, Graziela Reis, worked as a psychologist in Brazil and now works as a project coordinator in Yale’s Department of Psychiatry. Like Costa, she was unable to continue her career in the U.S.

In Brazil, clinical psychologists must earn a master’s degree, but here, they need a Ph.D. The family decided they couldn’t afford to pay for Reis to go back to school, both because of the cost of tuition and the income they’d have to forfeit for her to stop working. She expressed frustration at the regulations for herself, but also for Costa, who was a successful psychiatrist with years of experience and teaching under his belt in Brazil.

“You have experience — your residency, work experience, professorship, whatever else,” she said. “What else do you need to prove?”

Reis says the roadblocks that internationally trained health care workers face are particularly nonsensical, as the workforce shortages and need for culturally competent care are so dire. She said that, for example, she’s heard of children getting misdiagnosed as on the autism spectrum or adults getting incorrect mental health diagnoses just because they don’t speak fluent English.

And those cultural differences can go beyond language, Costa explained.

“It is implied that if you have Spanish as your first language that you will provide culturally competent services for all Spanish-speaking Latinos,” said Costa. “But we come from different countries, different cultures, you know? But services are not tailored.”

But, ultimately, Costa believes that, with immigration being such a contentious issue on the national stage, it’s difficult for governments to find support for the development of culturally competent care for immigrants.

“If the system was interested in providing very good health care for Brazilians, they would be interested in people like me,” he said.

Correction: A previous version of this story incorrectly defined the acronym ACGME, which stands for Accreditation Council for Graduate Medical Education.