Task Force on Immigrant IMGs
Meeting #1: July 30, 2014, 8:30-10:30 a.m.
Northwest Area Foundation, 60 E. Plato Blvd, St. Paul 55107
Meeting Notes
Task Force members present: Yende Anderson, Edwin Bogonko, Donna DeGracia, Sue Field, Jane Graupman, Wilhelmina Holder, Tedla Kefene, Christine
Mueller, Kris Olson, Mimi Oo, James Pacala, Barbara Porter, Jinny Rietmann, Michael Scandrett
MDH staff: Ed Ehlinger, Mark Schoenbaum, Darcy Dungan-Seaver, Teri Fritsma, Deb Jahnke, Nitika Moibi
Guests: Rep. Rena Moran, Rep. Jim Abeler, Munir Hattar (NAAD), Juliana Milhofer (MN Medical Association), James McClean (HealthPartners)
Agenda
Meeting opening
•
•
•
•
Welcome from MDH
(Dr. Edward Ehlinger,
Minnesota
Commissioner of
Health) and the
Minnesota
Legislature (Reps.
Rena Moran and Jim
Abeler)
Introduction of
Chairperson (Dr.
Edwin Bogonko)
Introductions of all –
Task Force members
+ guests
Review agenda
Notes/Discussion
Welcome
Commissioner Ehlinger welcomed all, and thanked Task Force members for volunteering to work on
this challenging, even intractable issue. He described how the Task Force came about, and urged
members to be creative in exploring how to integrate and use the talents of these clinicians in
today’s health care system, likening the possibilities to the innovation that created the dental
therapist profession in Minnesota.
Commissioner Ehlinger then introduced the two legislators whose work created the Task Force:
Reps. Rena Moran and Jim Abeler. Rep. Moran emphasized the importance of finding a path to help
these physicians thrive in a field they love, and urged members not to restrain themselves to old
paradigms. Her hope is that this work could lead to something that could become law, not only to
help the physicians themselves but also so they can serve others.
Rep. Abeler said he often heard people say these physicians were “just not good enough.” He urged
members to address this bias head on, remembering that dental therapists met a lot of resistance
too. Minnesota is the ideal place to figure out how to integrate international physicians into the
workforce. He urged members to ask questions and be forceful in pushing the status quo. Could the
state create a program in which foreign-trained physicians could work in Community Health Centers
(CHCs), perhaps in a physician assistant-like role, and if they do well there, be authorized to practice
more broadly? We have a crisis, particularly in CHCs and rural areas, and Minnesota can be a national
leader in addressing it.
Commissioner Ehlinger noted that later today, Governor Dayton will be appointing him to a Task
Force to look at the U’s Medical School. He’ll be monitoring this Task Force so he can bring its work
to that group as well.
Action Items
Agenda
Notes/Discussion
Introduction of Chair
Commissioner Ehlinger then introduced the chairperson for the Task Force, Dr. Edwin Bogonko. Dr.
Bogonko is a physician at St. Francis Medical Center and is representing the Minnesota Medical
Association on the Task Force. He described his own experience as an international medical graduate
and his past work on this issue. For him, it comes down to the question of “why,” given that evidence
supports the idea of providers speaking the same language and even looking like their patients, and
given that Minnesota has such a high percentage of refugees and other immigrants. He urged
members to explore how we can create more gravitas around this issue.
Introduction of Task Force Members
Dr. Bogonko then asked other members to introduce themselves and indicate one tangible outcome
they’d like to see the Task Force produce:
James Pacala is with the University of Minnesota Medical School, which has been working for several
years on this issue, including through its Preparation for Residency Program (PRP). In that program, 5
of 6 participants secured residencies.
Kris Olson is with Essentia Health, and is interested in this issue both from a recruitment standpoint
and as a Midwesterner. She’d like to see primary care open up more.
Donna DeGracia has been involved with Physician Assistant (PA) education for 15 years and is
currently with the PA program at St. Catherine University. A significant part of her own practice as a
PA has been with refugees and immigrants.
Yende Anderson is with the Council on Black Minnesotans, which worked with Reps. Moran and
Abeler to get the Task Force bill through the Legislature. She also used to work at New American
Alliance for Development (NAAD), and is excited to see this long-term effort come to the forefront.
Mimi Oo is a physician from Burma and now with NAAD. She was unable to secure a residency in the
U.S., even with experience as a physician with the United Nations. Minnesota now has a large
Karen/Burmese population, and she wishes she could serve them as a doctor. She’d like to see the
state develop a distinct Rural and Urban Underserved Residency Track.
Tedla Kefene was a general practitioner for 4 years in Ethiopia and 5 more in Saudi Arabia. He has
taken 3 of the USLME (U.S. Medical Licensing Examination) steps. One difficulty is we’re still working
within an old system, and one that doesn’t reflect all the immigrants who have arrived in Minnesota
since the 1990s. Using these physicians could minimize the cost of education; we might look to
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Action Items
Agenda
California’s system as a model.
Notes/Discussion
Wilhelmina Holder is a physician who came here 30 years ago, and has worked to help other
physicians enter the system. Last year, 37 of the physicians NAAD works with applied for residencies,
7 obtained a residency, and 2 remained in Minnesota. She’d like to see Minnesota retain more of
these skilled physicians.
Jane Graupman is with the International Institute of Minnesota, which 25 years ago started a
Medical Careers Pathway program. They’ve helped place 1,800 new Americans in the health care
system, including 387 who’ve become RNs and LPNs. She’d like to see the Task Force dig into the
data around need, and the talent that could help address that need.
Barbara Porter is with College of Medicine at Mayo. She’s in the Office for Diversity, but is also
administrator of the Mayo Quality Academy. She sees her role as helping hold the Task Force to a
quality framework, and she’ll be emphasizing data. Mayo sees the community enriched by a diverse
population and physician population. She has seen many interpreters and others who have a medical
degree but could be doing more as a physician. She prefers the term “internationally trained
physicians” to “foreign-trained.” We need a pipeline, a pathway, so we can say to Mayo: You must
open your doors.
Michael Scandrett works with various groups that help low-income and uninsured populations,
including Community Health Centers, community mental health providers, and community dental
providers. He’s not an expert on the details on this issue, but knows we are really missing an
opportunity to match our workforce with the populations who need them.
Jinny Rietmann is with Workforce Development, which is headquartered in Rochester but serves a
10-county area. She heads up their Foreign-Trained Healthcare Professionals program and works
with about 50 foreign-trained physicians. She has two goals: in the short term, to find funding to help
individuals get through the process; and in the long term, to increase the percentage of these
physicians working in the U.S.
Sue Field is with HealthForce Minnesota, a Center of Excellence within MnSCU (Minnesota State
Colleges and Universities) that works to match MnSCU programs with needs. They were very
involved with the development of Community Health Workers. She is representing MnSCU on the
Task Force, but in a prior life worked with foreign-trained physicians who went through a nursing
program.
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Action Items
Agenda
Notes/Discussion
Christine Mueller is with the U’s School of Nursing. She is interested in how professional nursing
could be a pathway. The U currently has a 16-month graduate program for individuals with a
baccalaureate degree or higher, and 17 of those credits apply to the nursing doctorate, including
programs for nurse practitioners and other Advanced Practice RNs (APRNs).
Mark Schoenbaum of MDH noted members who were not able to attend today: Jibril Elabe and
Adalberto Torres, both of whom are both currently in residency and therefore may not be able to
attend all the meetings; and Michael Grover of the Federal Reserve Bank of Minneapolis.
Introduction of staff and guests
Dr. Bogonko asked staff and guests to introduce themselves. Mr. Schoenbaum, director of MDH’s
Office of Rural Health & Primary Care, welcomed everyone and encouraged members to see his staff
as resources. Other MDH staff introduced themselves: Darcy Dungan-Seaver, who will be the lead
staff person for the Task Force; Nitika Moibi, supervisor of the health workforce planning and
analysis program; Teri Fritsma, senior workforce analyst; and Deb Jahnke, primary care coordinator.
Other guests introducing themselves were Munir Hattar, a physician with NAAD; Juliana Milhofer,
with the Minnesota Medical Association (MMA), and James McClean of HealthPartners.
Foundations of Task
Force
•
•
•
Review charges and
overall goal of
recommendations
Review proposed
process, ground rules
and timeline
Discuss key terms,
any other
clarification/
adjustments needed
Review of charges and overall goal
Dr. Bogonko then turned to the specifics of the Task Force’s assignment, emphasizing that
recommendations to the Commissioner of Health and Legislature must be complete by January 15.
He reviewed the overall charge from the session law (2014 Minnesota Session Laws, Chapter 228,
Article 5, Section 12), and the 5 more specific parts of that charge. (See meeting presentation for
more detail.)
Dr. Holder asked if Charge #1, which refers to refugees and asylees specifically, could be broadened
to all immigrant physicians. Mr. Schoenbaum said the Task Force does have that flexibility; the intent
was just to distinguish this group of physicians from those who come into the system through J-1
visas and other nonimmigrant routes.
Dr. Holder also asked if we could add to Charge #4, regarding alternative pathways, the task of how
to acknowledge individuals’ prior experience in these alternative programs – how not just to identify
alternative roles, but how to customize training given this prior experience and not require that they
begin all over again as if they have just graduated from high school. This would also save costs. Dr.
Bogonko noted this was an important goal and is somewhat achieved in nursing already. Ms.
DeGracia noted it would be important to make sure the physicians the scope of practice of each
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Action Items
Agenda
Notes/Discussion
alternative. Ms. Field mentioned that MnSCU recently adopted a policy and procedure for credit for
prior learning, and this might be something the Task Force may want to explore.
Rep. Moran noted that the charges as listed are slightly different from what she recalled. She
questioned why Charge #2, which directs the Task Force to identify foreign-trained physicians who
are interested in meeting the requirements to enter medical practice or other health careers, is
necessary. If we create a pathway, these individuals will emerge. The current framework comes from
a deficit position – how can we be more proactive instead? The key things she heard listening to
members’ introductions were access to clinical training and creating a system that integrates these
physicians into the workforce. The focus should be on how to create access.
Ms. Anderson suggested that Charge #1, regarding demographic analysis, be changed to the overall
challenge of how to integrate the physicians into the workforce. MDH staff clarified that this overall
charge from the session law is listed on Slide 2, and Charges 1-5 listed on Slide 3 also come directly
from the session law as specific tasks required of the Task Force. Charges 1 and 2 will be largely data
collecting and analysis that can be accomplished fairly quickly; Charges 3-5 will form the guts of the
Task Force’s work.
Ms. Anderson also commented that for Charge #4, regarding alternative pathways, it will be
important to keep the focus on integrating physicians as physicians, with alternative pathways good
but it is important to keep as many in the physician role as possible. Dr. Oo noted that alternative
pathways might be a good route for those who can’t pass the USMLE or other tests.
Dr. Bogonko reminded members that answering Charges 1-5 will provide the framework for the
overall recommendations, and will help inform legislators and others who might know the issues as
well as members do. All of these ideas about integration will make their way into the report.
Review of proposed process, ground rules and timeline
Dr. Bogonko reviewed the proposed ground rules (Slide 4), including decision-making by consensus
as much as possible. His hope is that any differences will be in style versus substance, and that
members will speak from their hearts and be mindful that a respectful environment will drive the
creation of quality recommendations. Members will need to stick to the facts, but also forge lasting
relationships to make it more than an academic exercise. He asked if anyone had any changes or
comments to this approach. Dr. Holder asked if the meeting start time could be changed to 9:00, and
members agreed to this adjustment. Ms. Graupman offered the International Institute of Minnesota
as a location if needed.
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Action Items
Agenda
Work on Charge #1
•
Review/discuss
highlights of
physician workforce
analysis and identify
any additional
information needed
Notes/Discussion
Dr. Bogonko then asked MDH staff to present the proposed timeline. Ms. Dungan-Seaver reviewed
the proposed 6-month work plan (Slide 5), which calls for having draft recommendations for review
at the December meeting (to be submitted in time for the January 15 deadline) and monthly
meetings between now and then, with possible smaller work group meetings in between.
Action Items
Ms. Dungan-Seaver also reviewed key terminology from the session law that members have
expressed an interest in clarifying (Slide 6). In particular, a more precise alternative to the term
“foreign-trained physician” might be “immigrant IMG (international medical graduate)” to
distinguish this group from J-1 and other nonimmigrant IMGs, and from U.S. citizens who train
overseas and are also usually included in the term IMG. Similarly, rather than narrow the scope to
refugees and asylees only, the intent of the session law seems to be immigrant physicians generally.
Change “foreign-trained
physician” to “immigrant
international medical
graduate (IIMG)” in Task
Force materials.
Members agreed these were good clarifications, and Dr. Bogonko suggested that the Task Force’s
output include better definitions for these various subgroups, which are sometimes treated
differently under different programs and sometimes have an easier to route to residency and other
experiences. These distinctions will be important in defining who qualifies for which programs. He
suggested a glossary be developed, and that the definitions be used consistently in the Task Force’s
work.
Ms. Dungan-Seaver presented MDH’s initial work on Charge #1, noting this is very much a first look
at the current physician workforce (and only those licensed). She encouraged members to review it
with an eye toward how it can be used in the final report and recommendations, and thinking about
what additional data/analyses might be useful. Most of this initial data comes from the Board of
Medical Practice and a survey MDH conducts of physicians when they apply for or renew their
license. (See Minnesota Physician Workforce Demographics for the specifics of this presentation.)
Develop a glossary of key
terms.
Questions/comments from members:
• Ms. Porter noted that Slide 10, showing the regional breakdown of foreign-trained
physicians, suggests we should look into the southwest region more deeply. What is
occurring there that the percentage of foreign-trained doctors is so much higher (24 percent)
than other regions (which range from 8-19 percent) and the state overall (at 14 percent)?
Perhaps we could interview the big employers there. MDH staff can also analyze its J-1 data
to see if many of these are former J-1s. Dr. Holder noted that many J-1s don’t stay in the
rural or underserved areas they serve on their waivers, but Mr. Schoenbaum said many do
and MDH can provide that retention information for the Task Force to review.
• On slide 11, showing the countries in which Minnesota’s foreign-trained physicians received
their medical education, Ms. Porter questioned whether Minnesota really has 7 or fewer
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Dig deeper in the
southwest region numbers
and possible reasons for
the relatively high
proportion of IMGs there.
Bring more data on J-1
physician distribution and
retention.
Agenda
Notes/Discussion
•
•
Work on Charge #2
•
Update on survey of
immigrant physicians
in Minnesota
physicians trained in Somalia, and noted if that is the case, the Task Force has its work cut
out. Dr. Pacala confirmed that that number is probably correct. Ms. Moibi pointed out that
these are the countries of education and not necessarily birth; some Somali physicians may
have received their degrees in Ethiopia or elsewhere, and therefore wouldn’t show up under
Somali in this listing.
On Slide 12, showing the specialties of Minnesota physicians overall compared to those
trained outside the U.S. and Canada, members were interested in more information on the
“No certification” category and numbers. MDH staff will find out more on which physicians
this category includes and why a greater proportion of IMGs have no certification compared
to U.S.-trained physicians (38 versus 19 percent, respectively). Dr. Bogonko also noted that
this graph excludes the 2,623 physicians who did not provide a business address to the
Board. MDH could re-run the numbers by home address, though it is likely more report their
business address.
On Slide 13, showing languages communicated other than English for clinical purposes, the
comparison to the percentage of Minnesota households with school-aged children where
the language is the primary one spoken is not an ideal comparison with the survey question
asked of physicians. Members wondered if MDH could obtain information on the demand for
interpreters as a better indicator, perhaps from hospitals.
Ms. Dungan-Seaver asked members if there were other data or analyses members would find
helpful. Members suggested the following:
• Data from residency programs: Race/ethnicity, countries of origin, and visa status.
• Residency slots left vacant, covering past 10 years.
• Per capita ratios for key immigrant populations: e.g., the ratio of Somali physicians to Somali
individuals in Minnesota.
Ms. Dungan-Seaver briefed members on a survey MDH has developed to help address Charge #2.
The survey contains about 30 questions across a range of questions, including those on past training
and professional experience; demographic information; interest in meeting the requirements to
enter medical practice or other health careers in Minnesota; interest in exploring alternative
professions; and ideas for other possible solutions. The survey has been open since July 21 and will
remain open until August 11, or longer if necessary. Participants come from a list of 240+ contacts
provided by NAAD, as well as other networking (e.g., with refugee resettlement agencies and other
community-based organizations). MDH will report initial results from the survey at the September
meeting.
Dr. Pacala had some specific questions he’d recommend be asked in the in the survey, and will
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Action Items
Find out more on which
physicians are included in
the “No certification”
category and why so many
more IMGs are in the
category.
Investigate whether IIMGs
are less likely to report a
business address.
Look into better language
data, perhaps on demand
for interpreters.
Obtain data in these three
categories.
Report survey results at
September meeting.
Follow up with Dr. Pacala
Agenda
provide those to MDH staff.
Notes/Discussion
Work on Charges #3-5
Ms. Dungan-Seaver presented some of the early thinking from members on Charges 3-5, as provided
in a brief email questionnaire sent out before the meeting. (See Slides 9-11 of the meeting slides for
specifics on this presentation.)
•
Questions/comments from members:
• Ms. Anderson noted that NAAD has a video on its website that sheds further light on the
questions of barriers and costs, and asked if this could be added to the Task Force website.
• Mr. Schoenbaum encouraged members to think in terms of the types of barriers and costs,
too: which are institutional, which players and decision makers are involved, and which are
amenable to change at the state level versus federal, etc.
• Dr. Pacala noted that it’s not just a matter of passing the USLMEs (though those exams in
themselves are important and serve as a bottleneck). It’s also about language and the need
to become acculturated to the U.S. health care delivery system.
• Dr. Bogonko: Public health should be added as another alternative profession – can include
work in education, population management and research.
•
•
Presentation on early
thinking from Task
Force members
Review/discuss
framework for
evaluating pathways,
barriers and
opportunities
Discussion: Anything
else needed by the
Task Force –
research, speakers?
Action Items
on suggested additions to
the survey.
Add NAAD video to Task
Force website.
Ms. Dungan-Seaver presented a proposed framework for delving deeper into these charges,
beginning with a draft of the current pathway immigrant physicians must take to become licensed in
Minnesota (Slide 12). She suggested using pathway document as a tool for shared understanding and
for identifying the barriers that physicians experience, and from there alternatives and possible
funding sources.
Questions/comments from members on the draft depiction of the current pathway:
• Dr. Pacala noted that the Match program now has an “all-in” policy that means residency
programs must offer all their residencies through the Match, and can no longer offer backdoor deals into residency. Ms. Anderson asked if any residencies can still be offered outside
the Match, and whether it is voluntary or required. Dr. Bogonko noted some private colleges
are still doing residencies outside the Match. MDH staff will research the issue to clarify how
the different types of residencies are operating. Members also asked for more information
on who is funding non-Medicare slots, and how this works in the case of countries like Saudi
Arabia, which appears to be essentially buying U.S. residencies for its physicians.
• Ms. Anderson noted that NAAD recommends that IIMGs complete Step 3 of the USLME
before applying to residency, and suggested a footnote on that be added to the pathway
document.
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Research “all-in” policy at
Match and gather more on
non-Match residencies –
how they work, who is
funding them.
Add NAAD
recommendation on Step 3
to pathway.
Agenda
Meeting close
•
•
Review action
items/next steps
Next meeting
Notes/Discussion
Ms. Dungan-Seaver asked members if there were other data or analyses members would find helpful
for these charges.
• Dr. Pacala asked for a brief on the UCLA program by the next meeting.
• Ms. Porter asked for more information on southwest Minnesota and the comparatively high
number of IMGs practicing there.
• Dr. Bogonko asked for more information on J-1 physicians and retention.
Dr. Bogonko encouraged members to review and understand the current pathway; this will form the
basis of identifying barriers and possible solutions. Members will also be asked a new set of
questions and to share their thoughts on program models and possible funding sources. At the
August meeting, members will likely break out into 3 groups, and members should anticipate
working together between meetings.
Action Items
Develop brief on UCLA
program.
Research SW Minnesota
data and reasons behind it.
Gather more data on J-1
physicians in MN.
Send new set of questions
to members before August
meeting.
The next meeting will be held August 20 from 9:00-11:00 a.m. MDH staff will be contact members
with the location.
Next meeting: August 20, 9:00-11:00 a.m. , Hiway Federal Credit Union, 840 Westminster Street, St. Paul.
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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