Task Force on Immigrant IMGs
Meeting #2: August 20, 2014, 9:00-11:00 a.m.
Hiway Federal Credit Union, 840 Westminster Street, St. Paul
Notes – Meeting #2
Task Force members present: Yende Anderson, Edwin Bogonko, Sue Field, Jane Graupman, Michael Grover, Wilhelmina Holder, Tedla Kefene, Christine
Mueller, Mimi Oo, James Pacala, Barbara Porter, Jinny Rietmann, Michael Scandrett
MDH staff: Mark Schoenbaum, Darcy Dungan-Seaver, Deb Jahnke, Nitika Moibi
Guests: Munir Hattar (NAAD), Bonagh Dalton (SEWA/NAAD), Mina Ghorashi (NAAD), Kim Goodwin (NAAD), Mahmood Alatbee (NAAD), Ahmed Alathee (NAAD),
Juliana Milhofer (MN Medical Association), Ryan Merz (MN Department of Employment and Economic Development), Jaya Durvasula (NAAD/AAFACD).
Agenda
Meeting opening
•
•
•
Welcome and
introductions
Review of notes from
July meeting
Review agenda
Work on Charge #1:
Current MD workforce
•
Updates/additions to
physician workforce
analysis based on TF
feedback
Notes/Discussion
Dr. Bogonko welcomed members, staff and guests to the second meeting. He asked any Task Force
members who were not present at the July meeting to introduce themselves. Michael Grover is
Assistant Vice President for Community Development at the Federal Reserve Bank of Minneapolis,
and previously worked in MDH’s health workforce planning and analysis unit. Staff and guests
introduced themselves as well.
Dr. Bogonko asked if anyone had changes to the July meeting notes (none did). He then reviewed the
Task Force’s overall charge, and today’s agenda based on the specific tasks within that charge.
Dr. Bogonko reviewed the charge to analyze demographic information of current medical providers
compared to the population of the state. Ms. Dungan-Seaver presented data collected by MDH staff.
See Minnesota Physician Workforce Demographics – Follow Up for the specifics of this presentation,
which covered the following questions and requests members had regarding the initial workforce
presentation in July:
• Whether IMGs might be more likely to not to supply a business address to the Board of
Medical Practice (data indicate they are only slightly more likely – 13% of IMGs do not supply
an address vs. 11% of U.S.-trained physicians).
• Why the southwest region of Minnesota has such a high share of physicians of color and
IMGs relative to other regions of the state (it’s still unclear: the region has a more diverse
physician workforce than the state in all racial groups, with the majority of these physicians
of color also IMGs; the IMGs come from many different countries, with the distribution of
countries very similar as across the state as a whole; and only 24% are J-1 waiver recipients,
so the high proportion of IMGs in the region is not necessarily explained by J-1 visa
placements). Mr. Schoenbaum summarized how the J-1 visa system works.
• Why licensed IMGs are less likely than U.S.-trained physicians (USMGs) to be board certified
Action Items
Agenda
Notes/Discussion
•
(appears to be a function of the length of time they have been licensed, with IMGs more
likely to have held a license for a shorter period, and less likely to be board certified within
the first three years of licensure, likely reflecting the fact that many undertake fellowships
and additional training that requires a license but not necessarily board certification. For
physicians who have held their license longer than three years, the difference in board
certification among IMGs and USMGs is much less significant).
The ratio of IMGs per immigrant population, by country (with especially high ratios for Laos,
El Salvador, Vietnam, Liberia, Honduras, Cambodia and Somalia).
Questions/comments from members regarding southwest Minnesota and J-1 data:
• Dr. Pacala noted that it may be worthwhile to look at the size of the towns in which IMGs are
practicing in the southwest region (and others); that might shed further light on their
distribution and the reasons behind it. MDH will provide this analysis.
• Dr. Oo noted it will be important to look at the breakdown of IMG applicants accepted into
residency programs in Minnesota, to see how many are J-1s vs. Minnesota residents.
• A guest noted that because of the time required for training and education for a medical
specialty, the five-year residency requirement affects physicians who specialize. She also
noted that Minnesota in general is considered an unfriendly state for IMGs, and cited an
example of an acquaintance who was accepted into prestigious programs in New York and
California, but didn’t get into any Minnesota residencies.
• Mr. Scandrett urged the group not to spend too much time on the J-1 issue, as those
physicians are outside the focus of the Task Force. Dr. Bogonko agreed, but noted it will be
important to be able to sift out the various subgroups of IMGs, so we can zero in on this one.
• Ms. Graupman noted that areas with a significant number of IMGs, even if they are mostly J1s, are important in part because those communities may be more attractive to other IMGs,
including IIMGs.
• Ms. Rietmann also noted that some J-1s are unable to return to their home countries.
Questions/comments from members regarding the ratio of immigrant populations to IMGs from
those countries:
• Dr. Pacala noted that important conclusion of this data is that overall, certain immigrant
communities – particularly those from east and west Africa, and southeast Asia – are grossly
underrepresented in Minnesota’s physician workforce. And this is much less so for
populations from other regions of the world. This is something to keep in mind with
strategies that target specific needs, such as the UCLA IMG program, which focuses
specifically on Spanish-speaking communities.
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Action Items
MDH will provide more
detail on rural distribution
of IMGs.
When residency program
data is compiled, include
how many IMGs are J-1s vs.
Minnesota residents.
Agenda
•
•
•
Notes/Discussion
Members expressed concern that the numbers for certain immigrant populations may be
low. Dr. Bogonko noted that the Somali population in particular seems undercounted,
especially relative to the health care costs attributed to it. There was discussion regarding
whether the 21,227 figure for Somalis accounts for secondary migration into Minnesota, and
whether the federal Office of Refugee Resettlement) ORR might have additional data at least
on refugees (though not other immigrants).
Mr. Grover explained the pros and cons of this kind of census data, and noted that accuracy
is always an issue with such decennial estimates. He suggested indicating the confidence
intervals of each, as it will be larger for some populations than others, and to try to obtain
more specialized data where possible.
Mr. Schoenbaum asked for help in identifying other sources of immigrant population data,
and Dr. Bogonko asked members to send MDH any ideas or sources they might have.
MDH will look into these additional sources, and will also present the following at future meetings,
as requested by Task Force members:
• Data on J-1 retention in the state.
• Data on residency programs: demographics and trends in slots filled/vacant over past 10
years.
• More background on the Match “all-in” policy and non-Match residencies.
Work on Charge #2:
Identifying IIMGs
•
Update on survey of
immigrant physicians
Work on Charge #3:
Barriers/costs
•
Review/discuss
pathway framework
with barriers added
Dr. Bogonko asked members to continue thinking about the demographics and distribution of the
state’s foreign-trained physicians, as Task Force members will need to be experts on the topic.
Ms. Dungan-Seaver gave a brief update on the survey MDH has developed to help address Charge
#2. Initially scheduled to end in early August, MDH is keeping the survey through August to give
more opportunity for additional responses and more time for physicians outside NAAD’s base list to
hear about the survey and contact MDH.
Ms. Dungan-Seaver presented a summary of barriers identified thus far by members and through
additional MDH research (see “Barriers” on the pathway document). The barriers are based on the
physician licensing pathway presented at the July meeting, and grouped into four categories: (1)
barriers faced at the individual level; (2) barriers within the higher education system; (3) barriers at
the level of state policy; and (4) barriers at the national/federal policy level. These were presented in
draft form, and the Task Force was asked to review them for additions or other changes.
Questions/comments from members on barriers:
• The issue of social isolation is important, particularly for female physicians and those coming
from traumatic situations, including domestic violence. Ms. Graupman added domestic
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Action Items
MDH will investigate other
sources for immigrant
population counts.
Members will send MDH
any ideas or sources for
this.
MDH to present additional
analyses on J1 retention
and residency programs.
MDH to report initial survey
results at September
meeting, depending on
survey close date.
Agenda
Notes/Discussion
•
•
•
•
•
violence is pervasive and a common barrier for immigrant women, so providing support for
these situations is crucial. A guest noted that having access to student loans or other credit
might help in some of these situations, where the women might otherwise be trapped and
unable to pursue becoming licensed in their profession. Dr. Bogonko wondered whether the
Task Force could find 2-3 professional women willing to tell their stories. Dr. Holder said her
group knows such women, and Ms. Anderson noted that the NAAD/WISE video includes
powerful stories as well and is available via the Task Force website. Dr. Kefene suggested
also including stories from IIMGs who have successfully become licensed and are serving
their communities.
Dr. Dalton described her experience in a residency program here in Minnesota in which only
2 of 64 residents were IMGs. She said residency programs will sometimes keep slots vacant
rather than accept an IMG; the Match is first filled with USMGs, then IMGs, as there is a
perception that having more IMGs will affect the reputation of the program. Dr. Pacala said
that at least in the case of the family medicine programs in Minnesota, this was not true –
maybe 10 years ago, but not today; there has been a real shift. Now it’s not unusual for an
IMG to be ranked higher than a USMG in the program. Ms. Porter said there is a similar
commitment at Mayo. She feels it is important to dispel misconceptions about this and Mayo
seeks to be transparent, so she is willing to help obtain data on this issue. Dr. Bogonko
agreed that IMGs are often more competitive than USMGs. He also noted that HCMC was
starting to accept more IMGs when he was a resident there, and they have always had a
good reputation as a program even with a high number of IMGs. Mr. Schoenbaum said the
issue of bias cannot be dismissed, and that while there is some evidence about it in the
literature, it is difficult to document.
Ms. Anderson said that age discrimination is an issue as well, and is reflected in the various
time limits (such as the requirement most residency programs have that an applicant has
graduated from medical school in the past 3-5 years). Dr. Oo stated that that now is the time
to change the filters used by the training programs, which are preventing many qualified
physicians from getting through, despite their qualifications.
Dr. Bogonko noted another barrier is the scarcity of training programs in Minnesota relative
to the number of refugees and immigrants in the state’s population.
Dr. Pacala said a related barrier is the severe problem of a lack of clinical preceptors. The
medical school has a terrible time finding enough people to train its own students, and
adding another group of trainees will compound the problem. Dr. Bogonko noted that the
growing time and productivity pressures on physicians are part of this issue.
Dr. Holder suggested figuring out a way to assess IIMGs, to see how much clinical experience
they’d even need - some kind of assessment and custom training for them, which would
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Action Items
Agenda
Notes/Discussion
•
•
•
•
•
•
likely result in reduced training resources needed. Dr. Dalton noted that in New York,
specialists can get licensed without a residency. She also wondered how many IIMGs go into
fellowships, and if this could be make easier to do.
Dr. Bogonko noted there would need to be incentives in the system for that; right now there
are no incentives to change the system or make exceptions; it becomes the path of least
resistance. He gave the example of himself, required to take English tests when he arrived
even though he has spoken English since he was 4 years old, or the case of a Russian
physician he knows with years of experience who has been unable to practice. It’s
discouraging to see the loss that subsequently happens, but it comes back to our charge:
What can we influence, which barriers do we have influence on, even if those are initially
small steps?
To understand some of the higher education barriers more fully, Dr. Pacala suggested the
Task Force may want to invite John Andrews, Associate Dean for Graduate Medical
Education at the U, for a Q&A (or Dr. Pacala could forward a list of questions to him). Dr.
Bogonko agreed this was a good idea, and encouraged members to review the draft list of
barriers, add to it, and think of remaining questions they have.
Dr. Holder noted the Task Force still needs information on how non-Match and nonMedicare-funded residencies work. Dr. Oo suggested also looking at AmeriClerkships.
Dr. Pacala suggested adding the cap on residency slots funded by Medicare to the barriers,
and noted that if the Task Force recommends creating alternative residency slots, it takes
$130,000-150,000 per year, per resident, or a total of $500,000 to train a family medicine/
primary care resident.
Ms. Porter wondered if the Task Force was jumping to interventions before fully analyzing
the problem. Dr. Bogonko suggested members may want to form a subgroup to dig into
these barriers more fully, and to allow more physicians to tell their stories. Ms. Porter said
this group could also benchmark some of the pathways/strategies, and that Mayo research
could help with this.
There was discussion about the barrier of needing U.S. clinical experience to obtain a
residency, but this being very difficult when regulations prohibit unlicensed physicians from
practicing. Dr. Oo cited a related problem of unlicensed physicians not being credited for
CME (continuing medical education), and Dr. Bogonko confirmed CMEs are only available to
licensed physicians, so this is another barrier.
Dr. Bogonko proposed setting up two subgroups, one to look more closely at barriers and one at best
practices. He asked if Dr. Pacala to lead the former and Ms. Porter to lead the latter, and they
agreed. Members and guests were asked to sign up for one or both groups, which will meet between
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Action Items
Agenda
Work on Charge #4:
Alternative pathways
•
Discuss proposed
approach to
evaluating
Work on Charge #5:
Strategies/funding
sources
•
•
•
Review/discuss
models of past and
existing programs/
strategies, including
UCLA IMG program
Break out into
smaller groups to
discuss
Report out
Notes/Discussion
full Task Force meetings.
Ms. Dungan-Seaver explained briefly that in late August and early September, MDH staff will be
working with members from the University of Minnesota, MnSCU (Minnesota State Colleges and
Universities system), and St. Catherine’s to develop a framework for exploring alternative pathways,
particularly those for physician assistants and advanced practice registered nurse (APRN) professions
such as nurse practitioners.
Action Items
Review/discuss alternative
pathways at September
meeting.
Ms. Dungan-Seaver introduced a list of strategies that have been tried here in the U.S., presented
according to the phases of the pathway they seek to address, as a starting point for discussion (see
“Strategies Used” on the pathway document).
She then presented an overview of the UCLA IMG program, as requested at the July meeting (see
Program Brief: UCLA IMG Program). Among the questions still to be answered: (1) the percentage of
program participants who make it into residency; and (2) how it is funded (more detail, particularly
on the role of the California Medicaid reform fund). Dr. Pacala offered to forward any questions to
Dr. Patrick Dowling, one of the founders of the program. Dr. Oo noted that Brenda McGuire of NAAD
also has talked to Dr. Dowling and could be a resource as well.
Dr. Holder announced that WISE has received a Bush Foundation grant to explore the development
of a public-private partnership to increase residency training opportunities for IIMGs, and she is
hopeful this will be helpful to the Task Force’s efforts as well.
Dr. Bogonko then asked members, guests and staff to form two groups to: (1) review the initial list of
strategies/models, adding any that are missing or that the group would like to learn more about; (2)
discuss possible strategies for Minnesota, picking from the list or generating new ideas; and (3) using
the worksheet distributed to record the group’s discussion. The groups then worked separately and
reported back.
Ms. Porter reported Group #1’s ideas:
1. Providing opportunities for clinical experiences.
2. Customized training programs that avoids the need for full residency training.
3. Alternative certification processes or licensing categories, with the group interested in
learning more about how the recently created dental therapy profession as an example of an
alternative category of licensure.
4. Increasing the funding/slots for residencies, possibly using state/federal Medicaid waiver
funding in new ways.
5. Using application fees for J-1 waivers (paid by employers) to pay for costs of clinical
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Send follow-up questions
to the UCLA program.
Agenda
Meeting close
•
•
Review action
items/next steps
Next meeting
Notes/Discussion
Action Items
experiences.
6. Developing a comprehensive prep program like UCLA’s.
7. Providing more funding for USMLE test preparation programs.
Dr. Bogonko reported Group #2’s ideas:
1. Funding for a comprehensive program to help IIMGs prepare for existing residencies (similar
to the UCLA model).
2. Funding to create residency slots designated specifically for IIMGs.
3. Programs that would bypass the residency training requirement (some form of certification
or other mechanism).
4. An incentive program for sponsors of residency programs, with part of it designated for IIMG
development, but sponsors free to use the rest of the funding for other residencies as they
see fit.
5. A state-level program like MERC (the Medical Education and Research Costs program) or
folded into MERC that would fund or create residencies designated for IIMGs.
6. Conducting coordinated fundraising strategies for these ideas, going to entities like the
Council of Health Plans and foundations, particularly corporate foundations like Medtronic
and Cargill that have an interest in a strong health care system in Minnesota.
Dr. Bogonko thanked the group for today’s discussion. The Task Force has lots of hard work to fit into
6 months, and more subgroups may be needed between full meetings. He encouraged members to
be open to new ideas and to think not only of themselves, but of the people coming behind them.
MDH will give form to the ideas on the worksheets, and at the end of the day, the group must have
smart strategies ready, not only for the Legislature but for the many entities that will need to be on
board: the hospitals that sponsor training; those required for a public-private partnership; and the
ACGME (Accreditation Council for Graduate Medical Education) and others who make rules about
training and licensure.
Present a synthesis of the
groups’ ideas at the
September meeting, in part
based on the worksheet
detail.
The next meeting will be held September 24 from 9:00-11:00 a.m. at the Northwest Area
Foundation.
Next meeting: September 24, 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
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