The article is republished from Stateline, an initiative of the Pew Charitable Trusts.
It took 11 years for Vladislav Zimin to complete his training in Russia to become an interventional cardiologist, a specialist who places stents in clogged arteries. After that, he practiced for five years, ultimately becoming head of his Moscow hospital’s cardiology and radiology department.
Then he emigrated to the United States in 2015 at age 32, and had to practically start all over again.
He spent seven years studying English and preparing for the rigorous U.S. Medical Licensing Examination needed to qualify for an American residency, which he’ll begin in July in Brooklyn. For him to get back to performing invasive heart procedures, he’ll have to repeat three years in residency, three years in a general cardiology fellowship and one year in a fellowship for interventionist cardiology.
By then, he’ll be 47.
“It’s downshifting, that’s for sure, a very humbling experience,” he said.
He was only able to do it thanks to savings and the money his wife earned—as a waitress for a time—to support the couple and their young daughter. After a couple years, he went to work as a consultant with expertise on medical devices to make a living while completing all the steps needed to practice medicine in the United States.
“You have to be open minded, you have to realize it’s going to be a big challenge, but at the same time you get to prove yourself all over again that you deserve to be a doctor.”
Increasingly, states are eying immigrants like Zimin, foreign-trained health professionals, as part of a solution to two problems that have deepened during the Covid-19 pandemic: the growing shortage of health care workers as the overall population in the country ages, and the worse health outcomes experienced by minority and immigrant communities.
As many as 270,000 underemployed immigrant health care professionals are now living in the U.S., according to a report released last month by the Migration Policy Institute, a nonpartisan research organization that analyzes immigration. Many have taken low-paying jobs as Uber drivers or cashiers just to stay above water. Zimin and many others would rather be practicing medicine.
A handful of states are easing certain licensing requirements, creating programs for foreign-trained doctors to work alongside U.S.-trained ones, reserving residency spots for immigrant health workers and providing help, sometimes including financial aid, for those working to get a U.S. license. States hope the efforts can not only get medical providers to more places where they are needed—particularly underserved rural and urban areas—but also lead to more professionals who speak the same language as and are culturally attuned to those they treat in an ever more diverse America.
“With help from the government, mostly at the state and local level, we could maximize use of the skills and knowledge of people already here,” said Jeanne Batalova, a senior policy analyst at the Migration Policy Institute and a co-author of its report on foreign-trained, immigrant medical workers.
Some states, such as Colorado, Illinois, Missouri and Washington, now allow foreign-trained doctors and sometimes other medical professionals to work under certain conditions, such as under the supervision of doctors licensed in those states. Some of those measures are in force only during the Covid-19 public health emergency, which has strained hospital staffs and prompted many to leave their jobs and others to consider doing so.
Minnesota has created a program that provides clinical experience to doctors who trained overseas so they can compete for medical residencies, and has set aside state-funded residencies for international medical graduates. The state also assists nurses trained elsewhere to gain English proficiency and prepare for the nurse licensing test.
Colorado is considering legislation that would help foreign-trained doctors get licensed, including assistance with preparing for the medical licensing exam and scholarships to aid in paying for those tests, which cost at minimum nearly $3,000. Arizona’s legislature is mulling a measure to help foreign-trained doctors to get licensed.
Meanwhile, a task force in Massachusetts and state-created work group in Washington are developing recommendations on ways to help doctors and nurses trained overseas to get credentialed in their states. The Illinois legislature also passed a bill this year creating its own work group. That measure is awaiting the governor’s signature.
“It behooves us to figure out what barriers can be removed without compromising patient safety,” said Illinois state Rep. Theresa Mah, a Democrat, who sponsored the bill.
Hurdles to Licenses
It generally costs immigrants who trained as doctors elsewhere at least $10,000 and four to five years to get relicensed here, according to Jina Krause-Vilmar, president of Upwardly Global, an organization that helps highly skilled immigrants find work in their chosen profession in the United States.
For those fleeing conflict zones, political repression or natural disasters, the climb toward licensing can be particularly steep.
“It is often the case that these migrants leave their homes in a rush,” said Batalova of the Migration Policy Institute. “When people grab the most valuable things, it may not be degrees and transcripts that will be essential later on in undergoing the licensing process here. In some countries, for refugees it is virtually impossible to get a letter from their educational institution that they have their degree and this is the coursework they did.”
Every state requires foreign-trained doctors to complete a medical residency, even if, as in Zimin’s case, they already did one in their home countries. To compete for a residency, immigrants must have their qualifications approved by a credential evaluation agency to determine that they meet U.S. standards. That alone weeds many out.
Then they must pass two parts of the three-part U.S. Medical Licensing Examination. (The third part is taken during the residency.) That is especially difficult for those who have been out of medical school for years and are not native English language speakers.
Zimin said his deficiency in English caused him to fail the second part of the test twice.
Applicants for medical residency also must have clinical experience in the United States to gain familiarity with the American health care system. U.S.-trained students usually get that in their fourth year of medical school.
“If you don’t have a license or training from a U.S. institution, where do you get that experience?” asked Mah, the Illinois state representative. “A hospital isn’t going to hire you. It’s almost a circular problem that people find impossible to navigate.”
They usually must do what Zimin did: persuade a hospital or health clinic to let them work as a volunteer and then write a letter on their behalf to a residency program.
States Assist Immigrants
The Minnesota legislation, adopted in 2015, created a program that pays for a nine-month clinical rotation for four international medical graduates each year at the University of Minneapolis Medical School. The $350,000 a year program is meant to help those students compete for medical residency slots, said Yende Anderson, who leads the state program assisting international medical graduates at the Minnesota Department of Health.
Competition for medical residencies is keen for everyone, but particularly for international medical graduates, Anderson said. “Admission directors don’t like seeing people who are more than five years out of school.”
For that reason, the Minnesota law also funds two or three residency slots a year for international medical graduates. Funding this year is $200,000, Anderson said. Residents must agree to train in a primary care specialty and to serve for five years in a rural or medically underserved area of Minnesota. They will have to pay back a small portion of the cost of the residency after it ends.
Mah, who chairs the Illinois House Health Care Licenses Committee, said she is hopeful her state also will soon fund residency slots for international medical graduates. The Colorado task force last summer proposed something similar.
Creating slots for immigrants serves a public purpose in a state with a significant minority and foreign-born population, Anderson said.
“We have people in the immigrant community who go to a doctor and receive medicine that they never use because no one else in their community has ever used it before,” said Anderson. “But if they hear about it from a provider from their community, that makes a difference.”
The Minnesota law also provides funding to nonprofits that coach international medical graduates applying for residencies and pays for study aids and other help.
Other states have tried to get doctors into the workforce right away. Washington’s law passed last year provides a limited license that enables foreign-trained doctors to practice medicine under the supervision of a doctor fully licensed in the state.
Washington in 2016 passed a law creating another type of limited license that allows foreign-trained doctors to teach and practice in medical schools. After three years, that limited license can be upgraded to a permanent one without a medical residency.
“These people are already teaching next generation physicians, so why wouldn’t we let them become fully licensed physicians themselves?” said Micah Matthews, deputy executive of the Washington Medical Commission, which handles medical licensing in the state.
Nurses from overseas face similar challenges, even though they’ve received less legislative attention. To get licensed in most states, they must pass English language and licensing tests. They also must submit documentation to an approved accreditation evaluation agency to determine if coursework they completed in other countries meets the standards of the state where the nurse wants to be licensed.
That documentation can be a challenge for immigrants whose countries are in turmoil, said Allison Cohn, a member of the Massachusetts task force and the educational case manager at the Welcome Back Center in Boston, which helps foreign-trained nurses get credentialed in the state.
Accreditation agencies usually take more than a year to complete evaluations, Cohn said, keeping nurses sidelined. And if the evaluation finds gaps, such as the absence of psychiatric clinical work, that means the applicant must try to find nursing education programs open to accepting students for those specific courses.
This year, the Minnesota legislature appropriated $400,000 to assist nurses and other health professionals through the licensure process, including helping them assemble the documentation they need.
Despite the slow process, Zimin, the Russian émigré, insists he doesn’t feel aggrieved. He said states have an obligation to ensure that those they license are competent and understand the complexity of the American health care system.
“It’s our own choice. I know there are challenges. I know it is difficult. But nobody said being a good doctor, doesn’t mean it’ll be easy.”
Michael Ollove is a Stateline staff writer.