Medical Licensing Policies and New York State s Physician Shortage

1. Medical Licensing Policies and New York State’s Physician Shortage New York State Board for Medicine January 18, 2008 Medical Society of the State of New York Committee on International Medical Graduates Parag Mehta, MD, Chair

2. IMG Committee Goals for this Meeting Foster understanding To help each other help the people of New York State Help ensure that qualified physicians are available to all New Yorkers Make the most of New York State’s investment in GME Address concerns that licensure policies drive qualified physicians out of the state to practice. Convince the Board that benefits of eliminating disparities in licensure requirements for IMGs and US graduates outweigh any perceived risks.

3. OVERARCHING GOALS  Ensure that access to medical licensure is based strictly on quality determinations. Ensure that when communities are struggling to find physicians, qualified individuals are not inappropriately deterred from practicing in our state.

4. FACT Critical physician shortages exist in many parts of New York State.

5. FACT: Some of New York State’s current licensing policies drive many New York State-trained physicians to practice in other states.

6. FACT New York State trains more physicians -- and more IMGs -- than any other state

7. Facts About International Medical Graduates Represent more than 40% of the state’s practicing physicians Comprise an even greater percentage of residents and fellows training in New York State Represent a major source of care to underserved communities

8. Facts IMGs have demonstrated a greater willingness to practice in underserved areas than their US graduate counterparts. IMGs are more likely to specialize in primary care than are US medical graduates.

9. Historical Background USA saw huge growth in demand for physicians in 1950’s through mid-70’s, when preferential visas ended Forerunner to ECFMG established in 1956 to validate IMGs’ educational credentials and administer a medical science exam and test of written English Preferential visas for IMGs ended in mid-1970’s Visa Qualifying Exam – shorter version of NBME Part I and II exam for US students and graduates – was introduced

10. Historical Background(continued) 1989: IMGs were eligible to take NBME Parts I and II 1994: USMLE steps 1,2 and 3 became the exam for all physicians for US licensure To Enter Residency Training Today: USMLE Step 1; Step 2 – Clinical Knowledge (CK); Step 2 – Clinical Skills (CS), including ICE (Integrated Clinical Encounter); CIS (Communication & Interpersonal Skills); and SPE (Spoken English Proficiency)

11. New York Adopted Special Licensure Policies for IMGs to Address Two Major Concerns: that the curricula in medical schools not accredited by the LCME might not be equivalent to those in US schools that applicants might submit fraudulent credentials.

12. New protections addressing both concerns have since been built into the system.

13. Concerns about both curriculum and fraud are addressed Transcripts are reviewed prior to admission to residency training and in applying for licensure. Strict controls do not permit credentialing documents to pass through applicants’ hands.

14. Other assurances of quality have been added throughout the educational and testing processes.

15. The Steps to Licensure for IMGs in New York State Education: ECFMG and EICS review and primary source-verify medical school curriculum, transcripts and graduation Exams: USMLE I, II Clinical Skills Assessment: History, Physical and Patient Notes Communication & Interpersonal Skills –gathering and sharing information; manner and rapport Spoken English Proficiency – clarity of spoken English communication within doctor-patient encounter

16. The Steps to Licensure for IMGs in New York State (continued) Visa – Review by Dept. of Homeland Security Residency Program Director Review At interview for admission During 1st PGY year, based on Residency Review Committee and ACGME core competency requirements Hospital HR Department Review FCVS: Curriculum, transcript and primary source documentation of all credentials for licensure FCVS does not permit credentialing documents to pass through applicants’ hands at all.

17. The Steps to Licensure for IMGs in New York State (continued) Three or more years of approved graduate medical education Passage of USMLE Part III.

18. Question: What are the licensure policies that are make it difficult to retain New York state-trained primary care physicians?

19. Licensing Policies of Concern to IMGs Three-Year GME Requirement for IMGs vs. the One-Year Requirement for US Graduates Requiring FCVS to make up to 5 attempts to document IMGs’ undergraduate educational credentials Requiring Those Wishing to Sit for the USMLE to Apply for NYS Licensure at the Same Time.

20. Licensing Policies of Concern:Three-Year GME Requirement THE POLICY LIMITS OPPORTUNITIES For Residents Some residency programs require residents to be licensed after the first year of training. IMG candidates are excluded from consideration for such programs.

21. Licensing Policies of Concern:Three-Year GME Requirement THE POLICY LIMITS OPPORTUNITIES Post-Residency Primary care physicians completing three-year residencies can’t begin employment if licensure is delayed. Further delays in credentialing for hospital privileges, Medicare participation or managed care panels must be expected.

22. Licensing Policies of Concern:Three-Year GME Requirement THE POLICY HURTS EMPLOYERS AND COMMUNITIES IN NEED Communities suffer and employers are short handed until licensure, hospital privileges and enrollment in managed care panels have been obtained.

23. Licensing Policies of Concern:Three-Year GME Requirement THE POLICY DRIVES FAMILY PHYSICIANS OUT OF STATE Family Physicians cannot sit for their specialty Board exam until they hold a full and unrestricted medical license. IMGs completing training in Family Medicine must either apply for licensure in another state to qualify, or wait until they have completed training and received a New York medical license. Lack of Board Certification adds another competitive disadvantage for IMGs seeking to begin practice in New York State.

24. SOLUTION FOR IMGs? Many IMGs obtain licensure in other states and accept positions outside New York while awaiting licensure here.

25. Changing Circumstances Support a Change in the 3 year GME Requirement  Today, a single written examination for licensure, rather than separate tests for US graduates and IMGs, allows for accurate comparison of test results.

26. Changing Circumstances Support a Change in the 3 year GME Requirement  The state now has the benefit of the clinical skills assessment examination to help provide assurance that the clinical preparedness of IMGs is on a par with that of US graduates. Numerous published studies have shown that the performance of IMG residents compares favorably with that of USMG residents.

27. A May 1997 editorial in the Annals of Internal Medicine stated: “During the past 3 years, a trend in the performance of US graduates and IMGs on the ITE (In-Training Examination) has become increasingly apparent. “The scores of IMGs at all three levels of residency are higher than the scores of US graduates, and the gap is widening. The differences are highly statistically significant…”

28. A continuing trend In 2002, The Annals of Internal Medicine published “The in-training examination in internal medicine: An analysis of resident performance over time,” … concluding again that IMGs consistently outperformed USMGs.

29. Licensing Policies of Concern:Requiring FCVS to Make Up to 5 Attempts to Verify IMGs’ Undergraduate Credentials New York’s requirement that FCVS attempt up to five times to obtain documentation from the applicant’s home country is more rigorous than that of other states, slows the process considerably,

30. Licensing Policies of Concern:Requiring FCVS to Make Up to 5 Attempts to Verify IMGs’ Undergraduate Credentials The requirement leads FCVS to advise applicants to pursue alternate state licensure when there are delays leads IMGs to seek employment or practice opportunities outside New York.

31. Licensing Policies of Concern:Requiring FCVS to Make Up to 5 Attempts to Verify IMGs’ Undergraduate Credentials FCVS advises residents to begin the credentialing process in PGY-1, but large residency programs do not have the administrative capacity to document training annually.

32. Licensing Policies of Concern:Application for Licensure Required When Applying for USMLE in New York State IMGs are not eligible for NY State licensure when taking Part III of the USMLE, yet are required to apply and pay for licensure in order to take the exam. Many IMGs instead apply for licensure and take the exam in other states, increasing the likelihood that they will practice in those states.

33. MSSNY appreciates the Department’s special efforts to help IMGs  Appointment of a liaison to help in special cases of delayed licensure. Special assistance and alternatives for applicants whose schools do not respond to credentialing inquiries, or cannot be reached due to geopolitical difficulties.

34. POLICY CHANGES THAT WOULD HELP ADDRESS THE PHYSICIAN SHORTAGE : End the disparity in GME requirements between USMGs and IMGs. Reduce the number of attempts New York State requires the FCVS to make to obtain primary source documentation from overseas.

35. POLICY CHANGES THAT WOULD HELP ADDRESS THE PHYSICIAN SHORTAGE : Simplify the demands the FCVS makes on training institutions to document the same information repeatedly during the course of a resident’s training. Allow residency programs to submit documentation of anticipated GME completion six months prior to the completion of residency training.

36. SUMMARY FACTS: NYS has a shortage of physicians NYS has more residents than any other state IMGs provide care for underserved areas

37. SUMMARY FACTS (continued): IMGs have been credentialed or reviewed at every step in the process ECFMG and EICS verify medical school school graduation and curriculum Medical knowledge is evaluated by USMLE I and II Clinical skills are tested by US experts in the CSA

38. SUMMARY FACTS (continued): IMGs have been credentialed or reviewed at every step in the process Homeland security reviews applicant for Visa Program directors and hospital HR departments review qualifications Six core competencies have been evaluated during residency

39. SUMMARY FACTS (continued): IMGs have been credentialed or reviewed at every step in the process USMLE III and in-training exams by the specialty during first year of residency FCVS verifies credentials directly before licensing

40. SUMMARY FACTS (continued): The present system poses a significant delay in getting jobs, leading many IMGs to leave New York State The system for evaluating IMGs has evolved, but we have not changed the system for licensure

41. The Educational Commission for Foreign Medical Graduates (ECFMG®) established the International Credentials Services (EICS) in 2000 to assist international medical registration authorities in obtaining primary source verification of medical education and registration credentials of physicians applying for licensure whose medical education was completed outside their jurisdictions.

42. EICS offers assistance to these authorities by obtaining primary source verification of medical school diplomas, medical school transcripts, certificates of postgraduate training and certificates of medical registration.

43. ECFMG has world-class experience in the primary source verification of medical education credentials. Over the years, ECFMG has developed a unique medical credentials reference library representing more than 1,800 international medical schools. The reference library houses the names of medical school officials, authentic signatures and seals, and samples of verified diplomas.

44. 1910: Inferior quality colleges closed 1930: Physician: Population decreased 125:100,000 from 173:100.000 1959: Bane: 40000 shortage declared 1965: School Increased 93 to 140 1976 HEPA no more shortage declared 1985 Students increased to 16,950 from 7000

45. 1956 ESECFMG VQE ECFMG NBME USMLE USMLE CSA

46. 6 Core Competency Areas Patient Care Medical Knowledge Practice Based Learning and Improvement Systems Based Practice Professionalism Interpersonal Skills and Communication