Task Force on Immigrant IMGs
Meeting #3: September 24, 2014, 9:00-11:00 a.m.
Northwest Area Foundation, 60 E. Plato Blvd, St. Paul 55107
Notes – Meeting #3
Task Force members present: Yende Anderson, Edwin Bogonko, Sue Field, Jane Graupman, Michael Grover, Wilhelmina Holder, Tedla Kefene, Christine
Mueller, Kris Olson (by phone), Mimi Oo, James Pacala, Jinny Rietmann, Michael Scandrett (by phone)
MDH staff: Mark Schoenbaum, Darcy Dungan-Seaver, Nitika Moibi, Teri Fritsma, Anandi Somasundaram, Stephen Nguyagwa
Minnesota Board of Medical Practice (BMP) staff: Ruth Martinez
Guests: Munir Abdella (NAAD), John Andrews (University of Minnesota), Sonia Chowdhury (NAAD), Chinwe Chukoboh, Mina Ghorashi (NAAD), Abdi Gonjobe
(NAAD), Kim Goodwin (NAAD), Abubakar Hassan (NAAD),Munir Hattar (NAAD), Juliana Milhofer (MN Medical Association), Chukwudi Muojiese, Nadia Rini
(NAAD)
Agenda
Meeting opening
•
•
Welcome and
introductions
Review of notes from
September meeting
and review agenda
Work on Charge #4:
Alternative pathways
•
Notes/Discussion
Dr. Bogonko welcomed members, staff and guests to the third meeting. He asked if anyone was new
to the meetings, and several guests as well as presenter John Andrews introduced themselves.
Dr. Bogonko reported that he was asked to brief the Legislative Health Care Workforce Commission,
which was created this year to study and make recommendations to the legislature on how to
strengthen the state’s health care workforce. He asked Mark Schoenbaum of MDH, who is staffing
the commission, to report on that meeting. Mr. Schoenbaum explained there are a number of
health workforce efforts under way. The legislative commission has a broad charge with an emphasis
on primary care. He said Dr. Bogonko did a good job summarizing the work of the Task Force thus far
and generated interest in what can be done; the commission clearly showed a receptivity and
interest in what the Task Force will recommend. Dr. Bogonko discussed some of the questions
legislators had, including the lost opportunity of people going to other states for residencies, and
whether there is a need to increase the number of residency slots or increase funding (Dr. Bogonko
said probably both).
Dr. Bogonko asked if anyone had changes to the August meeting notes (none did) and reviewed the
agenda.
Dr. Bogonko introduced the Task Force’s charge to look at non-traditional pathways for IIMGs, an
issue the Task Force hasn’t explored much yet.
Presentation on RN &
Christine Mueller, Task Force member and associate dean for academic programs at the University of
APRN pathways at
Univ of MN (Christine Minnesota’s School of Nursing, gave a presentation on the nurse pathways at the U (see Nursing
Pathway for International Education Physicians: University of Minnesota, School of Nursing for the
Mueller)
specifics of this presentation), noting there are many other registered nurse (RN) and advanced
Action Items
•
•
•
Agenda
Presentation on PA
pathway (Donna
DeGracia, St.
Catherine’s
University)
Discuss barriers/costs
and potential
solutions
Assign work group
Notes/Discussion
practice RN (APRN) programs in the state as well.
Members had the following questions/comments:
• If an IIMG pursues an APRN degree such as nurse practitioner instead of a license to practice as
an MD, can they avoid having to do a residency? Correct, although some ARPN residency
programs are beginning to pop up around the country.
• What is the entry point? Assuming an IIMG has met the program’s prerequisites, they can enter
the Master of Nursing (MN) program, which leads to licensure as an RN. From there they could
enter the Doctor of Nursing Practice (DNP), which leads to licensure as an APRN (which includes
nurse practitioner, nurse anesthetist, nurse midwife and other professions), with some of these
requiring a national certification exam between the degree and licensure.
• Can an IIMG test out of prerequisites or other required courses? This currently isn’t possible, but
could be explored. Dr. Bogonko suggested it would be important for the Task Force to look into
opportunities to develop such alternatives. Ms. Mueller said it is important to note that nursing
is a different profession from a physician; the latter is focused on diagnosing and treating
disease, which nurses don’t do. For example, they do not treat diabetes; they help people
manage diabetes in the context of their environment, family, community, etc. NPs do some
diagnosis and treatment within their scope of practice, but it is still a profession rooted in
nursing and not medicine.
• How competitive are these programs? The master of nursing program at the U of M is quite
competitive (64 spots for 300 applicants), and is limited by the size of the faculty and available
training sites.
• What’s the employment market? The market for RNs is good across a variety of settings, and the
market for NPs is very good.
• Have they had any IIMGs in their program? Only one foreign-trained physician that she recalls,
and it was a long time ago.
• What about the RN-MSN (master of science in nursing) option? Those programs, such as one at
Metro State, are geared toward RNs who have an associate degree. MnSCU schools are doing a
great job working with these students. The U does not offer an MSN program like that; you must
already have a bachelor’s degree. A guest mentioned his wife is an RN and is getting a master’s
degree online.
• Dr. Bogonko suggested the Task Force should map all of the programs and pathways available,
including online options.
Donna DeGracia, Task Force member and curriculum director/academic coordinator for the physician
assistant (PA) program at St. Catherine’s, gave a presentation on the PA pathway (see Physician
Page 2
Action Items
Agenda
Notes/Discussion
Assistant: Education and Practice for the specifics of this presentation).
Members had the following questions/comments:
•
•
•
•
•
•
•
•
•
Why did they change the process whereby individuals could take the PA test without necessarily
having a PA degree? Ms. DeGracia was not part of the system at the time, but it seems to have
been decided for clinical quality reasons.
Regarding the two parts of the PA program (academic + clinical): Since many IIMGs have already
taken similar academic courses, would it be possible to test out of the academic requirements
and proceed to the clinical parts of the program? This is unlikely, given the differences across the
programs (it would be a program-by-program decision), the national standards, and the difficulty
finding clinical sites. In addition, at least at St. Kate’s, the academic courses are integrated with
the clinical components, though the university might consider it if the students still took part in
the academic coursework somehow (without having to pay for full credit, etc.). Finally, most
universities would miss the income if the academic pieces were skipped. Dr. Bogonko wondered
about the possibility of the schools being reimbursed for that loss.
The PA program seems most aligned with physician training. Yes, it is based on that, which is a
difference from the nursing path.
The PA pathway document refers to PA programs requiring clinical experience for admission –
what kind of experience must this be, and how would an undergraduate just out of college have
it? This varies a lot. Some have worked as personal care attendants, some as ultrasound techs,
and some as IMGs.
Would an IMG’s foreign clinical experience count toward this requirement? At St. Kate’s yes, but
it varies by program. One of the Minnesota-based PA programs requires at least a certain
amount of U.S.-based clinical experience.
The national certifying exam is run by a national organization, so that would be out of the state’s
control, correct? Yes.
What flexibility do the individual programs have in their academic requirements vis-à-vis the
national accrediting organizations? There’s some flexibility, but overall the requirements are very
strict. Still, it may be possible to develop a way of testing out of some of the required courses,
and it may be possible to look at using the USLME exams as a basis for meeting prerequisites.
How many graduates do Minnesota’s PA programs produce each year? Augsburg and Bethel
each graduate about 30 students, St. Kate’s will graduate 32 this year (its first class), and St.
Scholastica’s program begins in 2016.
Are clinical sites reimbursed for their costs? Not at present, though that is probably coming.
Currently most preceptors are volunteers. The problems arise not so much with individuals not
Page 3
Action Items
Agenda
Notes/Discussion
being willing to serve as preceptors, but with their institutions. St. Kate’s is trying to show how
preceptoring benefits sites. Dr. Bogonko noted problems that come up with physician training
sites as well, and wonders about incentives for regional hospitals to provide such sites.
Action Items
Dr. Bogonko proposed that the Task Force next set up a work group that can explore these
alternative pathways in more depth. Specifically, he’d like the group to do the following:
1. To look at alternative roles from a global perspective, including all the ARRN and PA
programs in Minnesota and perhaps models beyond it to find those that are the most
accommodating and/or affordable (including online options that might be more affordable,
at least in the case of PA programs, which in Minnesota are all currently private programs
and cost more than $70,000).
2. To include the costs and requirements of those options, keeping in mind that many IIMGs
are cash-strapped. Are there less expensive programs out there, or could there be?
3. To explore how we might create alternative pathways within these options for IIMGs – which
policies or requirements might be changed, tweaked or proposed? What tools might help
IIMGs access these programs?
Work on Charge #5:
Strategies/costs/
funding sources
•
•
•
Presentation on
Preparation for
Residency Program
(PRP) (James Pacala)
Presentation/Q&A on
Graduate Medical
Education (John
Andrews)
Report from Best
Practices work group
He suggested that Ms. DeGracia and Ms. Mueller be on the work group. Other volunteers were Ms.
Anderson, Ms. Field, Ms. Moibi, Mr. Gonjobe, Ms. Holder and Ms. Olson. Ms. Olson, who is vice
president of physician and professional services at Essentia, noted her special interest in this topic
from recruitment, credential and payer enrollment perspectives. Essentia currently has 96 open
positions that could be filled by PAs or NPs.
James Pacala, Task Force member and associate department head of Family Medicine & Community
Health at the U of M, gave a presentation on the Preparation for Residency Program (PRP), which ran
from 2010-2012 (see Preparation for Residency Program handouts for more detail).
PRP was a 7-month program that ran for two sessions, the first funded by a $150,000 appropriation
from the State of Minnesota. In the second year, the government shutdown led the funding to be cut
while the U was in the middle of recruiting the second cohort, so the university used its own funds to
complete that year’s program. The $150,000 did not cover all expenses; it was a very resource-heavy
effort with its intensive, 1:1 or 1:2 training in clinical settings and $1,000 monthly stipends to
participants (an important feature that addressed a key barrier the Task Force has also identified).
The program was suspended after 2 years, for multiple reasons:
• The lack of ongoing funding in a program requiring intensive resources.
• Competition for residency slots had increased, with a rise in the number of seniors in medical
Page 4
A work group led by
Christine Mueller will
investigate alternative
pathways, existing and
potential new strategies.
Agenda
Notes/Discussion
•
schools.
The number of qualified applicants dropped. This is the factor most difficult to talk about. In Year
1, 14 of the program’s 36 programs applicants met the minimum requirements. Even for those
14, there were significant hurdles: they averaged 1.5 attempts to pass the USMLE Step 1 (this
compares to an average of 1.1 times for the entering class of the U’s family medicine residency
program) and 1.9 attempts to pass Step 2 CK (compared to 1 try for all 49 of the entering class in
the residency program). There were other, similar data as well; it was a big barrier. Not only was
there competition for spots, it was difficult for PRP applicants to compete with other residency
applicants.
In Year 2, of the 4 individuals accepted, 1 left the program, 2 found residency slots in Minnesota and
1 found a residency position out of state. Overall, it was a successful program with modest numbers.
Members had the following questions/comments:
• Which qualifications were found lacking in the applicants to the PRP? It was a mix of issues:
passing the Boards on the third try; lack of English proficiency; and lack of typing skills, an
important issue with the wide use of electronic medical records (EMR).
• Dr. Holder noted that there is more to a physician’s competency than these 3 issues, all of which
can be taught. She hopes the U will look at other qualities and skills in evaluating candidates. Mr.
Pacala said this is an excellent point, but the PRP had limited resources and so couldn’t accept
candidates who didn’t speak English or couldn’t type; the program didn’t have the resources to
train in these areas.
• Ms. Anderson noted that these physicians also had to work full time, and had families and other
obligations, so finding time to study for and take the USLMEs could be more difficult for them.
She noted that NAAD added an English class for its participants after hearing from the U that
English proficiency and typing were issues.
• Mr. Gonjobe noted that publicity for the PRP was low. He could have applied, and knows of
other physicians who were volunteering and could have applied as well, but none knew about
the program. Dr. Bogonko suggested this was probably more a function of the premature end of
the program than anything else.
• Dr. Bogonko sees these questions as opportunities to fill the gaps, to help the U address these
issues. Our job is not to give every doctor a job, but to find and help competent people who are
having difficulties. How do we identify the pool of talent? The legislators on the workforce
commission asked how many IIMGs Minnesota has, so we need to inventory that population.
Can we also dissect the issues – the skills and other preparation needed – and then identify the
groups who can help address those gaps? He’d like to see us develop a pathway that includes
Page 5
Action Items
Agenda
Notes/Discussion
Action Items
organizations that can help an IIMG meet requirements along the way – all the issues that can
act as a barrier, even before an IIMG is eligible for residency.
• Ms. Graupman compared the situation to nursing: 25 years ago, many foreign-trained nurses and
nurse assistants faced difficulties passing the U.S. exams. So the International Institute
developed an 8-10 week program that is longer (and more expensive) than typical prep programs
at community colleges, but it has helped 144 individuals take the nursing assistant exam, and
they now outperform native English speakers.
• Given the physician shortage the state has, particularly in rural areas, we need to look at
developing a pilot program that accepts people who don’t necessarily meet the U’s current
standards.
• Ms. Anderson noted that $150,000 isn’t that much to raise, and the group could fight for it, as
NAAD has had to do for continued grant funding for its physician prep program.
• Ms. Goodwin from NAAD noted that the discussion is focusing on the “cream of the crop,” only a
few people who could be in a program like the PRP. We need to look at a bigger solution, such
as the model used in Germany. Dr. Bogonko agreed that many of the residency programs focus
on the highest scorers, but there are some – such as HCMC – that look at other indicators of
clinical acumen. Dr. Andrews from the U agreed that USMLEs alone are insufficient, but they are
important, as they are necessary for licensure and they are the single predictor of whether one
will pass Board certification. For most residency programs, passing the boards is enough, but
showing that you have difficulty passing is a concern. Ms. Anderson noted that this is why they
encourage their participants to take Step 3 as well, to show they can pass all steps.
• There was further discussion about whether scores were an accurate reflector of what kind of
clinician one is.
• As a next step, Dr. Bogonko asked Dr. Pacala to consider what make for an “ideal” PRP, and Dr.
Pacala agreed to bring those ideas back to the Task Force. Dr. Holder suggested that perhaps the Dr. Pacala will develop
ideas for an “ideal” PRP.
U could partner with Mayo in developing such a program.
Dr. Bogonko introduced John Andrews, Associate Dean for Graduate Medical Association at the U’s
Medical School, who agreed to come today to answer any questions members might have. He
offered help the Task Force going forward as well.
He explained a bit from the perspective of the residency program directors: They must select, based
on the information available to them, people they believe can successfully do the work in a
residency. This necessarily privileges U.S. graduates. The program directors can gauge better if those
graduates meet the requirements; they don’t know international systems well enough to compare.
That’s why the PRP and the UCLA IMG program are so important: they’re designed to assess these
qualifications better.
Page 6
Agenda
Notes/Discussion
Dr. Bogonko asked if there was capacity to add residency slots. Dr. Andrews replied that we might
get to that point with the increase in graduates, perhaps 5-10 years from now, but he doesn’t believe
we have a critical shortage of slots at the moment. We currently have enough and IMGs compete
well for them.
Mr. Schoenbaum asked about the “recency” issue (the requirement many residency programs have
that an applicant is a recent graduate of medical school). Dr. Andrews explained that this is not an
externally imposed requirement, but it is a common one. It comes from the idea that in a rapidly
changing health care system, we need people who’ve been trained recently. Mr. Schoenbaum asked
if he had any ideas on how this might be changed or addressed. Dr. Andrews said programs like the
PRP can help, by demonstrating that an IMG is qualified despite being out of medical school for a
longer time. The biggest insecurity the programs have is not having assurances of an applicant’s
qualifications, and programs like the PRP can help with that.
Dr. Holder asked if it would be possible to look at when the USMLEs were taken rather than the
graduation date. Dr. Andrews said graduating over 10 years ago doesn’t disqualify an applicant; the
difficulty is showing what you’ve done during that time and if it’s kept you up to date on medicine.
Dr. Holder said that NAAD has seen applicants thrown out just because of the recency issue, and Dr.
Andrews explained it’s an individual program-level decision. Dr. Rini said she has taken Step 3 but
graduated over 10 years ago, and there’s nothing she can do to change when she graduated. Dr.
Bogonko noted that even if you’re a Board-certified, licensed physician today, if you haven’t been
practicing for a year, that’s a big red flag to an employer. It’s why the advice he gives to IIMGs is to
volunteer in a clinic rather than work in a convenience store, and why need to help them with this
issue, so program directors have more to go on.
Dr. Andrews noted that perspective here is very important. Many of the instances we’re hearing
about today are about individuals, and we want to support them as much as possible. But a program
director must sift through 600 applications. They need some way of narrowing that field, by objective
criteria, to get to the number that can be interviewed. And in doing that, you miss good people. But
it’s hard to have an individual connection and knowledge. Dr. Bogonko noted it’s important to hear
this perspective, because these are real barriers.
Mr. Schoenbaum observed that many IIMGs have had to work in a convenience store (or similar job)
for 10 years because their lives were turned upside down and they must work to survive. What
advice would Dr. Andrews give them, given that it sounds like they wouldn’t be able to get in to a
residency? Dr. Andrews noted this “recency” issue is a problem not only for IIMGs, but for other
Page 7
Action Items
Agenda
Notes/Discussion
physicians too – such as women and other who’ve been out practice for stretches of time. They are
coming to the U and asking how they can be retrained. It’s related to how rapidly the health care
system is changing.
Action Items
Dr. Oo reminded members not to forget that the Task Force was formed because of issues around
health disparities in our communities, and that’s an important issue to keep in mind.
Dr. Holder wondered if IIMGs who were helped by NAAD could at least be interviewed by the state’s
residency programs. Dr. Andrews said he couldn’t speak for Mayo, but at the U, if there were a welldescribed program that could assess and explain an applicant’s qualifications, and especially if the
program were connected to the U, they could be interviewed. Dr. Holder suggested that the
strategies working group should look at what the requirements would need be for such a program,
so these applicants could be interviewed, or at least not screened out based on the recency issue.
Ms. DeGracia noted that St. Catherine’s offers rejected applicants the opportunity to have their file
reviewed and suggestions given. Often those applicants get in on a 2nd or 3rd try.
Work on Charge #1:
Current MD workforce
•
Questions/comments
on updates/additions
to physician
workforce and
residency data
Work on Charge #3:
Barriers
• Report from Barriers
work group
Dr. Bongonko noted that the number of residency programs in Minnesota is low compared to New
York and other states, and adding some may be part of the solution. He was asked by legislators if it’s
a question of funding for new slots in the state or preparation for existing slots, and he said it was
both.
Ms. Dungan-Seaver explained that workforce and residency data were sent out in advance. Dr.
Discuss residency data at a
Bogonko suggested we hold discussion on the data until a later meeting. Dr. Andrews noted he’d like future meeting.
to be part of that discussion, and has ideas on additional detail that might be helpful.
Dr. Pacala reported on the Barriers work group. One question was the “All-in” policy and possible
paths around it, and the idea of circumventing residency and going directly to a fellowship. Both of
these are questions Dr. Andrews could address at a future meeting.
Work group members had other ideas as well:
• Providing student loans/stipends.
• Hands-on clinical rotations.
• Using the date of exams instead of the date of graduation to determine an applicant’s “recency.”
Page 8
Agenda
Feedback forum
• Proposal from chair
to hold feedback
forum in November
Meeting close
•
•
Review next steps
Next meeting
Notes/Discussion
In addition, Dr. Pacala will provide his perspective on the “ideal” PRP, as requested.
Dr. Bogonko proposed that the Task Force hold an evening session to give IMGs and other physicians
and guests an opportunity to have a Q&A with the Task Force and to exchange information and
ideas, and to hear feedback on some of the strategies being considered. He’d like to identify a date
in November, and to invite physicians like one he has heard from at HCMC who would like to talk to
the Task Force. He’d also like to invite PRP graduates. He’d also like it to include some of the date the
Task Force has collected.
Dr. Bogonko thanked the group for today’s discussion.
Action Items
Organize an evening forum
in November for IIMGs and
others to provide feedback
and ideas.
The next meeting will be held October 22 from 9:00-11:00 a.m. at the Northwest Area Foundation.
Next meeting: October 22, 9:00-11:00 a.m. , Northwest Area Foundation, 60 East Plato Boulevard, St. Paul MN 55107.
Staff contact: Darcy Dungan-Seaver, MDH Office of Rural Health and Primary Care, (651) 201-3855 or [email protected].
Task Force web page: http://www.health.state.mn.us/divs/orhpc/workforce/iimg/index.html
Page 9