Layla Sulaiman, an Iraqi refugee, didn’t choose to come to the United States. It was chosen for her.
“We applied to United Nations, and we just wanted any place to resettle and to be safe,” she said.
It wasn’t safe for her in Iraq, where there was violence in the streets. Still, she served as a primary care OB/GYN for 17 years before she left in 2007. She now lives in Erie, Pennsylvania, with her husband and the youngest of their three daughters.
In this country, her medical license is no longer valid.
“I miss being a doctor. I miss it so much,” said 51-year-old Sulaiman. “I (was) never meant to be a housewife.”
Sulaiman is one of many refugees — though no one knows exactly how many — who practiced medicine in their home countries. Many are now in low-skilled jobs, driving taxis and working in grocery stores.
Underutilizing the skills of immigrants and refugees amounts to tens of billions of dollars in unearned wages that could be pumped back into the US economy, according to an analysis by the Migration Policy Institute, a nonpartisan think tank.
“The brain waste is appalling,” said Dr. José Ramón Fernandez-Peña, an associate professor of health education at San Francisco State University who studied medicine in his native Mexico. He is also the founder and director of the Welcome Back Initiative, which has helped foreign-trained providers get health care jobs in the United States since 2001.
“These are individuals who could be taking care of children with asthma and instead are working at a car wash,” he said.
President Trump backed a Republican-led immigration plan last week that would cap the number of refugees sent to the United States at 50,000: fewer than half of President Barack Obama’s 2017 goal of 110,000.
Doctors’ groups worry that restrictive immigration policies will reduce the number of foreign-trained doctors who fill health care gaps across America. If every graduating medical student in the US secured a residency slot, there would be thousands of slots left over.
The new immigration bill also favors highly skilled workers and gives “points” to those with advanced degrees, including medical doctors. However, if medical doctors are selected under the proposed system, they still face what many in health care have argued is a long, costly road to getting a medical license in the United States. This process hinders doctors like Sulaiman from going back to work, she said.
Sulaiman had hoped to be relocated to Australia, where her sister-in-law lives and where there are accelerated paths for foreign doctors. Had she gone to a country like Canada, she could have practiced with some restrictions while obtaining a full license.
But she ended up in the United States, where she must start her training from scratch.
“It’s a complete waste of people’s experience, talent and expertise,” Fernandez-Peña said.
Back to step one
Things began to turn around for Sulaiman starting in 2011 when her daughter’s principal suggested that she volunteer at school. She occasionally helped the school nurse take care of sick students, and other times, she toiled away in the cafeteria.
No longer idling at home, Sulaiman emerged from her depressed state and decided it was time to go back into medicine.
To do that, Sulaiman would have to apply to residency again — just like a medical student who has never practiced. Even if she gets into a program, it could require her to move across the country, away from the home she has re-established.
She would now be competing with thousands of newly minted doctors. She would also spend more than $5,000 preparing for and taking the exams.
“That’s become a bottleneck for training for people from abroad,” said Jonathan Weiner, professor of health policy and management at the Bloomberg School of Public Health at Johns Hopkins.
To apply, foreign doctors must take a series of hours-long exams, studying for weeks or months in English, which may or may not be their first language.
Refugees may have additional struggles, advocates say. For example, many must leave their home countries on short notice, making it difficult for longtime doctors to track down old transcripts and records.
Sulaiman passed these exams and applied to residency in 2015 and 2016. She hasn’t even gotten an interview.
Within the United States, there are more residency slots than medical students to fill them. This year, more than 22,000 American-educated students vied for nearly 29,000 first-year residency slots, according to the National Resident Matching Program.
The rest of these positions were filled largely by foreign graduates and US citizens who studied abroad, many in Caribbean medical schools. But they have a much lower acceptance rate: just over 50%. For American-trained MDs, that rate jumps to 94%.
Some experts predict a doctor shortage of 40,800 to 104,900 by 2030, according to an analysis commissioned by the Association of American Medical Colleges. The group has called for more residency positions to be funded.
Not all experts agree that there is an overall shortage of doctors, but many agree that there are regional shortages — in rural America, for example — and a shortage of certain types of doctors. Primary care physicians like Sulaiman are among those in short supply.
“I hear all the time there is shortage in doctors,” Sulaiman said. “We are just ready to help. We are ready to serve. Just give us a chance.”
To train residents at teaching hospitals, the federal government budgeted over $10 billion of mandatory funds in 2016. The majority of this money — about 90% — came from Medicare, and the rest came from Medicaid. These funds have been capped for 20 years.
The cap may also make the process more competitive for international doctors. American medical school enrollment jumped over 27% between 2002 and 2016, according to the Association of American Medical Colleges. But this did not mean 27% more doctors are being trained in the US.
With the funding cap, more American graduates may come at the expense of international doctors, according to Dr. Janis Orlowski, chief health care officer with the Association of American Medical Colleges. The association has said that both American and international medical students are necessary to address the nation’s health care needs.
Fernandez-Peña said that putting foreign-trained doctors to work in America is a no-brainer.
“Why not invest in this freebie?” he asked. “They’ve already been trained. We would be reaping the benefits that (another) country has spent money in training their work force.”
Ready to serve
Some experts have defended the long road to medicine in the US, saying that the process is necessary to ensure the best quality care.
“The primary mission of state medical boards is public protection,” Dr. Humayun Chaudhry, president of the Federation of State Medical Boards, said in a statement. “These requirements are put in place to ensure that only individuals who are fully qualified to practice medicine are granted licenses.”
Currently, he said, foreign-educated doctors in the United States come from nearly 2,000 medical schools in 160 countries.
“It is through this process that the public can be assured of a consistent level of health care,” Chaudhry said.
Other experts say that foreign-trained doctors may actually outperform their American peers in some ways.
“These guys often have better-honed clinical skills at the bedside than many of us will ever learn because they couldn’t rely on all the technology that we have,” said Dr. Atul Grover, executive vice president of the Association of American Medical Colleges.
A study published in February in the BMJ showed that US patients treated by foreign-trained doctors were less likely to die within 30 days of a hospital stay.
Groups like Fernandez-Peña’s Welcome Back Initiative continue to help doctors from around the world earn back their white coats in the United States. He is also working with the American Public Health Association and Rep. Lucille Roybal-Allard of California to introduce legislation that would help fund organizations that do the same kind of work.
Minnesota is one state that awards grants to programs that help foreign-educated doctors who want to work in the United States. Its Department of Health has a roster of nearly 150 international medical graduates in the state, but the office suspects there could be up to 400, according to a February report.
“The majority is working in literally — I kid you not — in the McDonald’s and driving taxis,” Fernandez-Peña said of the doctors he has met through the Welcome Back Initiative.
Sulaiman, however, said she has no plans to back down.
“I’m so hopeful that one day I will be able to serve at least my community here,” Sulaiman said. “They did a lot for me, and I’d like to serve them.”