Q&A: International medical graduates may help address severe PCP shortage in US

One of the top challenges facing primary care today is a severe workforce shortage.

By 2034, the Association of American Medical Colleges estimates that there will be a shortage of between 17,800 and 48,000 primary care physicians in the United States. Additionally, recent data from the Health Resources and Services Administration (HRSA) show that, as a whole, the U.S. has less than half of the PCPs its citizens need. About 99 million people are in one of 8,190 primary care professional shortage areas in the U.S. HRSA estimates that 17,063 primary care practitioners are needed to fill the workforce gap.

According to G. Richard Olds, MD, MACP, the president of St. George’s University in Grenada, international medical graduates could help address the primary care workforce shortage. Healio spoke with Olds to learn more about the severity of the shortage and potential solutions.

Healio: How severe is the primary care workforce shortage in the United States?

Olds: There is an overall shortage of doctors in general in the U.S. This has been going on for several decades. Since nearly two-thirds of U.S. medical school graduates specialize, and we need more than half to go into primary care, the shortage of primary care doctors has been growing disproportionally. COVID has also made this shortage worse since most primary care doctors support themselves in the outpatient area, and during the first year of the pandemic, about 10% of physicians closed their practices permanently. Indeed, by 2034, the Association of American Medical Colleges estimates the U.S. will face a shortage of up to 124,000 physicians. If in doubt, ask anyone in your area how difficult it is to find a primary care doctor these days. Even if you do find one, the question remains: will you actually see a doctor or a nurse practitioner or a physician assistant?

Healio: How did the shortage get to the point we're at now?

Olds: The overall doctor shortage started in the 1970s when a lot of new medical schools were built. By the 1980s, an article appeared that suggested we would have a doctor surplus based on managed care needs (with primary care doctors serving as gatekeepers, far fewer specialty visits would take place). Clearly, this approach to health management didn't work very well, but the fear we were training too many doctors persisted. Existing medical schools had little or no motivation to increase class size, and regulators made it very difficult to create new schools. As a result, for almost 30 years, no new medical schools were built, and existing schools did not increase their class size. Finally, by 2000 it was becoming clear that, with the U.S. population growing and aging, we were going to have a significant shortage of doctors. Florida State, in fact, had to sue the U.S. Medical School Accreditors (LCME) to get a new school open in the early 2000s. This was followed by a period of growth of new schools and expansion of existing schools, but that process is very slow, very expensive, and has now slowed down, but the demand keeps rising faster than the supply. For example, I built a new medical school during that period, and it took 7 years, cost $100 million, and only had 50 students in its first class.

Healio: How did the COVID-19 pandemic affect the shortage? And, in turn, how did the shortage affect the pandemic?

Olds: As I noted above, the pandemic closed about 10% of practices closed permanently. In addition, like many other professionals, a lot of doctors have taken early retirement and left the workforce. This was motivated in part by increasing workloads and the increased return on their retirement accounts. As a result, the real shortage is likely a lot worse than pre-pandemic estimates. The severe shortage of doctors clearly made the pandemic worse. Some states required a doctor, in the beginning, to order a COVID PCR test and later to receive antiviral treatment. If you didn't have a primary care doctor, this delayed testing and treatment. Alternatives such as clinics and hospital EDs were overwhelmed, which delayed admissions, testing, and treatment. Home testing has now helped but getting treatment is still an issue. All these factors undoubtedly resulted in excess mortality due to COVID.

Healio: How can international medical graduates help address the PCP workforce shortage?

Olds: For years, foreign-trained doctors have made up about 25% of the physician workforce. About 40% of these doctors are U.S. citizens who attend schools like St George's University outside the U.S., and 60% are foreign nationals who went to medical school in their own country or another country outside the U.S. Because U.S. medical school grads are not going into primary care or practicing in rural areas in large numbers, many international medical graduates have filled that gap. About 40% of the primary care doctors in the U.S. trained outside the states. At my university, 75% of our grads go into primary care fields while 25% specialize.

Healio: Rural areas are particularly impacted by workforce shortages. What efforts are needed to incentivize IMGs to practice in these areas?

Olds: The basic problem in rural America is students from rural areas don't get into U.S. medical schools proportionally to the 14% of people who live in rural areas. To understand this specific problem, you need to know why doctors practice where they do. About half of the decision is based on where they are from, while 50% of the decision is based on where they finish their residency training. Where they go to medical school has no effect on where doctors practice. U.S. citizens trained outside the U.S. are no different; they tend to practice where they came from and where they finished their training. Foreign-born doctors practice where they can get residencies and, later, jobs. As a result, in many rural parts of America, a significant share of doctors are foreign-born. The solution is ultimately to get more students from rural areas into medical school — any medical school — and create more residencies in rural America. Programs that pay doctors extra to practice in these shortage areas or forgive their medical school debt have not been very effective since a student from [New York City] is unlikely to stay in rural America after his/her debt is paid. On the other hand, recruiting students from rural communities and offering them scholarships if they return to practice has been successful. St. George's offers some scholarships on that basis.

Healio: Can you discuss the benefits of having a diversified PCP workforce in the U.S.?

Olds: In general, you want your health care workforce to look like the population they serve. There are many studies that show that Black or Hispanic doctors are more effective in communicating and caring for patients with a similar background. They are also more likely to work in underserved areas where they often come from. One of the less talked about aspects of the current doctor shortage is the fact that almost 80% of U.S. medical students come from the top two-fifths of economic status. We are largely training the sons and daughters of wealthy Americans. Only about 5% of U.S. medical students come from rural areas, while 14% of Americans live in rural areas. White and Asian doctors are also overrepresented among these classes. Diversity among medical students creates a better educational environment — students learn about different cultures and patient attitudes about health and disease from their fellow students. It is also helpful, since medicine is a mentoring profession, to have diversity among the faculty to create role models. We often only talk about diversity in terms of ethnicity, but economic diversity, educational background diversity, age diversity, sexual orientation diversity and rural/urban diversity are also important.

Healio: Is there anything else you'd like to add?

Olds: Experts often say that the reason U.S. medical students don't go into primary care is that we don't pay primary care doctors as much as specialists. Although true and undoubtedly one factor, in England, primary care doctors are paid the same as specialists, and English medical students all want to specialize as well. Often not talked about is the environment in which you train them. Most U.S. medical schools use large tertiary referral hospitals to train their students, and almost all their faculty are specialists. The same is true in England. This introduces a very strong bias against primary care. If you doubt that, ask your own primary care doctor how often he/she was told by the faculty at his/her own medical school that they are “too smart to go into primary care.” We at St. George’s have our students do their clinical rotations in teaching hospitals in the U.S. and England, which are mostly large community hospitals. Most of our faculty are primary care doctors. That is one of the reasons why so many of our students go into primary care. The other issue worth mentioning is the idea that the reason U.S. medical schools mostly take rich white and Asian students is that they are the “most qualified.” That is only true if you only look at standardized test scores and GPA. Each year, scores of students in the U.S. are qualified to get into medical school and would do well based on these metrics, but only 26,000 get in. If we look more broadly at all these qualified students, I think we would have better doctors in the end. This is what we did at UC Riverside. A student who didn't speak English until he/she was 8, never went to college prep or honors-offering schools, had to work through college, and still did well in both standardized tests and GPA, I would suggest, has traveled farther than a student with the same scores coming from affluent suburbs and many life advantages. In the almost 50 years I have practiced medicine, I have never heard a patient say the most important quality in my doctor is that they got an A+ in organic chemistry. I hear all the time that my doctor doesn't communicate with me well, doesn't seem to care about me, or seems eager to get out of the hospital. Give me a few more students who only got an A or B+ in organic chemistry but have good interpersonal skills and are motivated by the right reasons to be a doctor.

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