A shortage of physician-scientists in the United States is an ongoing problem. Various recommendations have been made to address this issue; however, none of them have ameliorated the situation. Foreign medical school graduates with postdoctoral training in the United States are an overlooked and untapped resource for combating the dearth of physician-scientists. Evaluation of the scientific staff at the University of Texas Southwestern Medical Center revealed that 11% of all postdoctoral fellows were international medical graduates. Interestingly, a survey taken by these individuals revealed a lack of institutional and/or mentor support for career development and preparation for becoming physician-scientists. Foreign postdoctoral fellows with medical degrees are not even eligible for physician-scientist grants and awards since they are not US citizens. Although physicians educated in the United States usually matriculate from medical school with high educational debt that prevents most of them from entering into scientific careers, doctors trained outside the United States generally have minimal, if any, debt. Furthermore, many of them have a keen interest in remaining in the United States once they complete their postdoctoral training. Thus, foreign-trained medical professionals who have pursued scientific training in the United States can be one of the solutions for the current dearth of physician-scientists.
- postdoctoral fellows
- international medical school graduates
- educational debt
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- postdoctoral fellows
- international medical school graduates
- educational debt
Importance of the Physician-scientist
Physician-scientists hold MD or MD/PhD degrees and perform biomedical research of any type as their primary vocation.1The opportunities for physicians to engage in medical research are enormous. Medical training provides physician-scientists with a unique perspective on disease pathophysiology that researchers with a PhD may lack.2Growing concerns about the lack of physician-scientists in the United States has been met with various recommendations, all of which focus on physicians educated in the United States.1,3,4
International medical school graduates (IMGs) constitute 25% of the physician workforce in the United States.5Many IMGs come to the United States for scientific training as postdoctoral fellows, and some stay to practice medicine. It has been shown that medical doctors are more likely to engage in research if they undergo postdoctoral training.6Many IMGs are interested in remaining in the United States after they finish their training in scientific research. Thus, IMGs-postdoctoral fellows represent a pool of scientists who are also trained in medicine. Therefore, one might propose that discussions about augmentation of the number of physician-scientists in the United States should include the possibility that IMGs with postdoctoral training are a source of physician-scientists.
Lack of Data
There are virtually no data on IMGs doing postdoctoral training in the United States. At one of the premier US academic institutions, the University of Texas Southwestern Medical Center at Dallas (UT Southwestern), postdoctoral researchers comprise approximately 10% of all employees. In February 2006, 514 postdoctoral fellows were employed at UT Southwestern. Eleven percent (58 of 514) of them were foreign medical graduates. Of that 11%, 28% (16 of 58) held both MD and PhD degrees. Thirty-eight of the 58 IMGs (66%) replied to an e-mail survey. The majority of them (31 of 38; 82%) indicated that they were interested in becoming physician-scientists. However, as indicated in Table 1 and from my personal experience, IMGs involved in postdoctoral training sometimes do not receive guidance from their mentors or institutions about becoming physician-scientists. Certainly, more survey data on this would be helpful.
Visa Status May Indicate a Postdoctoral Fellow's Intentions
Dissatisfied with opportunities in their own countries, IMGs are inclined to seek placement abroad.5Postdoctoral training in a US research institution may be the first step toward practicing medicine in the United States because it provides crucial factors for obtaining residency: (1) research experience and publications, (2) a recommendation from the US mentor, (3) opportunities to hone English language skills, and (4) an entry visa.
Although there is no career tracking system for IMGs who undergo postdoctoral training in the United States, indicators such as immigration status can give valuable information about their possible intentions. When starting a postdoctoral appointment, foreign nationals generally start with either a J1 or an H1-B visa. By definition, a person applying for a J1 visa does not expect at the time of application to stay in the United States longer than the visa itself as this is a visa for visiting scholars, not foreign workers. An H-1B visa holder can be the beneficiary of an immigrant visa petition, apply for adjustment of status, or take other steps toward Lawful Permanent Resident status without affecting his or her H-1B status.7Those who desire to stay in the United States seek to obtain an H1-B visa. The majority of IMGs-postdoctoral fellows at UT Southwestern who responded to the e-mail questionnaire, on which the data presented here are based, hold H1-B visas (24 of 38). An institution may have a quick look at the visa status of IMGs-postdoctoral fellows to obtain a clue about their aspirations.
Foreign Medical Graduates are Less Likely to Have a Large Educational Debt
When considering a career as a physician-scientist, medical students must weigh their interests in research against three factors: (1) accumulated debt, (2) a long period of training, and (3) the uncertainty of success.8When it comes to the first two factors, IMGs have an advantage when compared with US medical graduates. US medical school educational debt for those graduating from private medical schools in 2004 was more than $130,000, whereas those graduating from public medical schools had median debts of approximately $100,000.9Owing to this high level of debt, lucrative clinical practices and a high number of billable hours may be more appealing to US medical graduates than obtaining additional research training with paltry postdoctoral fellow salaries.
There is currently a great effort under way to entice clinician-scientists in the medical research by paying off their qualified educational debts via the National Institutes of Health (NIH) Loan Repayment Programs. If this initiative proves successful, it is possible that US-trained medical graduates can become a larger source of physician-scientists.
Unlike medical schools in the United States, most of the medical schools abroad are subsidized by the government. Students matriculate with low, if any, financial obligations. Thus, IMGs are less likely to be dissuaded by the relatively low wages offered by postdoctoral training programs. Those IMGs who start postdoctoral training have already accepted the fact that their training will be long and are actively working on the third factor mentioned above: research success.
Limited Availability of Awards and Grants
To make the transition from training to scientific independence, an aspiring physician-scientist on a postdoctoral level may think of applying for NIH-sponsored training grants and fellowships, namely T32 and F32 grants. Also, there are the K series of awards that promote independent research careers for young physician-scientists. However, these awards are not available to individuals on temporary visas. Candidates must be US citizens or noncitizen nationals or must have been lawfully admitted for permanent residence by the time of the award.10
A new NIH award was introduced in 2006, The Pathway to Independence Award (K99/R00), which is available to temporary visa holders. NIH decided to offer this award to non-US citizens with the explanation that scientific research is a global enterprise: “The Pathway to Independence Award seeks to attract the best and brightest individuals conducting research in the US, regardless of citizenship. This support should help transition them to research independence here in the U.S.”11If this is true for the K99/R00 award, the NIH could make all of its awards available to non-US citizens. Although the challenge for all is to identify the best and the brightest within the current system, some of them are certainly IMGs.
Those who are concerned about the dearth of physician-scientists in the United States may want to investigate (1) how many IMGs-postdoctoral fellows are working in American research institutions, (2) what their career plans are, and (3) how to foster their career development if they indeed want to stay in the United States and enter academic medicine.
To recruit and retain foreign medical doctors to do postdoctoral training and become physician-scientists in the United States, the following is necessary:
Raising awareness. Institutions need to be aware of the foreign medical doctors doing postdoctoral training in the United States and their potential for becoming physician-scientists.
Changing attitudes. A quarter of practicing physicians in the United States are foreign nationals. IMGs are obviously a necessity in the American medical system. Looking for physician-scientists to come solely from American medical schools has not met the demands of the US medical research enterprise thus far.
Changing behaviors. IMGs-postdoctoral fellows should have access to appropriate visas, citizenship, grants, and awards, as well as opportunities to become physician-scientists. Foundations, pharmaceutical and biotechnical companies, academic health centers, and the NIH should collaborate to develop a joint policy for supporting the clinical research and training of IMGs.
Conceivably, the question might arise about the taxpayers' return on investment for individuals with temporary visas. There is no assurance that those with temporary visas will be able to remain in the United States to serve as physician-scientists. Some of them may return to their home country for a variety of reasons. Also, IMGs who have already undergone residency and fellowship training outside the United States must repeat this training if they are to take on patient care roles.
This is obviously an area in which more research is needed to determine the percentages of the IMG-postdoctoral fellows with temporary visas who are willing to progress to conducting independent research as physician-scientists. Also, to justify spending of US tax dollars, more data suggesting that the return on the investment for IMG-postdoctoral fellows would be equal to or greater that that from US medical graduates are needed.
Academic medicine seems under pressure.12The physician-scientist appears to be a dwindling species.1,13,14However, IMGs are continually coming to the United States to do postdoctoral training. Many of these individuals hope to become physician-scientists. Therefore, it behooves the American research enterprise to realize the potential of foreign medical graduates with postdoctoral training and integrate them into the solution for generating sufficient numbers of physician-scientists in the United States.
Many thanks to Dr. Kara R. Lukin, Dr. Heather Gorby, and Dr. William F. Walton for the final language editing of the manuscript.
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