Since she was 2 years old, Elisa Tristan-Cheever dreamed of being a doctor. And by the time she was 30, she had a busy practice as a pediatric surgeon in Brazil.
But in the early 2000s, a financial crisis in Brazil prompted her to migrate to the United States with hopes of resuming her practice here. Instead, she found herself scrubbing toilets.
"Dunkin' Donuts, I worked in a laundry ... I worked as a host at Bertucci's ... delivering pizzas," she said. "And every night I was trying to study and applying."
Tristan-Cheever was applying for better jobs, and she was studying for the United States Medical Licensing Exam, which all doctors must pass before getting a residency. It's a crucible even for someone who hadn’t studied medicine in different country, which in Tristan-Cheever's case took more than 10 years.
She is one of roughly 3,000 foreign-trained doctors in Massachusetts not licensed to practice in the U.S., according to a 2014 report by former Gov. Deval Patrick's Advisory Council for Refugees and Immigrants. Jeffrey Gross of the Massachusetts Immigrants and Refugee Advocacy Coalition, one of the authors of the report, says that across the country there could be more than 60,000 foreign-trained doctors who are not licensed.
Pointing to a drought of doctors on the horizon, some are now calling for measures to assist foreign-trained doctors in meeting the stringent requirements needed to practice medicine in the U.S.
But others question whether there’s a looming physician shortage, and criticize American dependence on foreign doctors.
Dr. Fitzhugh Mullan, at the George Washington University Health Workforce Institute, says foreign-trained doctors are indispensable to the American health care system — about one in four doctors practicing in the United States were trained abroad. But there's no crisis in the fact that thousands of foreign doctors are unable to get licensed in the U.S.
Mullan says the real problem is the "brain drain" of doctors from poor countries to wealthy ones. He says the U.S. absorbs some 6,000 doctors from the rest of the world each year — India and Pakistan send the greatest number of doctors to the U.S. — the majority from countries that need their services.
Whatever the reasons for coming, the barriers to getting licensed in the U.S. can be insurmountable.
Tristan-Cheever, 49, says she learned what many foreign medical grads learn during the process: On paper it's relatively straightforward, but only if you have enough money and time can you properly dedicate yourself to preparing for the so-called "STEP" exams and other requirements that must be met.
She realized she had higher priorities — to bring her children and her parents from Brazil — and that required earning money immediately. Tristan-Cheever gave up trying to practice medicine, but she still feels a sense of injustice.
"Why [can we not] help in rural areas, helping people who need, who don't have insurance?" she said. "If we have so many doctors, nurses, physical therapists [who are] delivering pizza, cleaning houses?"
While some foreign-trained doctors are struggling to get licensed, others have resigned themselves to working in different fields. Tristan-Cheever is an administrator at Cambridge Health Alliance, and she’s working on a master’s in public health at Northeastern University. She says she could make another hundred thousand dollars as a doctor, but she's come to terms with that.
Foreign-trained doctors are common in Massachusetts. According to the state task force report authored by the MIRA Coalition, more than a quarter of the 33,000 doctors in the state are foreign born. And two-thirds of them were educated overseas.
“Nationally there's a projected shortage of physicians of more than 130,000 over the next decade," said state Sen. Jason Lewis, a Democrat from Winchester, chairman of the Joint Committee on Public Health, one of the advocates who say allowing more foreign-trained doctors to practice could satisfy future demand.
Lewis says Massachusetts is not immune from that shortage, particularly in rural areas.
"It's absolutely a critical need that we do have more physicians, and particularly being able to tap immigrant professionals is a great way to meet that need,” he said.
Lewis filed an amendment in the last budget proposal to examine the state of foreign-trained doctors in Massachusetts. The proposal was shot down, but Lewis says he plans to bring it up again in the current session. He says it's not about lowering the bar for foreign-trained doctors, but helping them get the opportunity to meet the standards in place.
The Last Obstacle: A Residency Match
Lewis learned of the challenges that immigrant doctors face from a constituent who did her training in Iran, 41-year-old Afsaneh Moradi.
"With all the respect I have for all the health care professionals, I was born to be a doctor, it's in my blood. I think like a doctor, I feel like a doctor."Afsaneh Moradi
"So many people they said, 'OK, you can do nursing, you can do [other jobs in the medical field].' With all the respect I have for all the health care professionals, I was born to be a doctor, it's in my blood. I think like a doctor, I feel like a doctor," she said.
Moradi came to the U.S. in 2004. After studying for five years, she met all the necessary requirements to practice medicine — the STEP exams, certification by the Educational Commission for Foreign Medical Graduates and proficiency in English — except one. Moradi now faces the highest barrier of all, landing a residency, and she’s been trying overcome it for another five years.
Nearly 95 percent of doctors who study at American medical schools get residencies, according to the National Resident Matching Program. But for those trained abroad, just half enter that elite circle.
So why the disparity? Experts say applicants' chances can drop based on factors such as multiple attempts at passing the STEP exams, a lapse in clinical experience, or the amount of time passed since graduating from medical school.
"There remains an assumption among [residency] program directors that if you went to a less well-respected medical school then you're probably not going to be a good doctor."Dr. David Scales
Dr. David Scales, a Cambridge-based physician with a doctorate in sociology, says an array of possible biases are at play that put foreign-trained doctors at a disadvantage. He calls a foreign medical degree "a weight on the scale" against them.
Scales says a major factor is the "prestige bias," which favors residency applicants who studied at more prestigious schools.
"There remains an assumption among [residency] program directors that if you went to a less well-respected medical school then you're probably not going to be a good doctor," Scales said.
Though experts say being a U.S. citizen and speaking native English improve one's chances at landing a residency, data from the Educational Commission for Foreign Medical Graduates show that citizens who graduate from foreign medical schools have nearly as much difficulty getting residencies as their non-citizen counterparts. In 2016, 54 percent of U.S. citizens who trained abroad landed residencies, compared with 51 percent for foreign-trained doctors without citizenship.
A Lack Of Residencies
Dr. Atul Grover, executive vice president of the American Association of Medical Colleges, says residency programs are better acquainted with domestic schools. But Grover points to another consideration; he says the number of residencies is not keeping pace with the growing demand for doctors, and the AAMC is calling on the government to fund 3,000 new residency positions over the next five years.
"Federal funding for residency positions has effectively been frozen since 1997, so we're looking at 20 years of saying we're not going to support our share of the costs for training physicians, which has led to, in large part, the physician shortage, when you couple that with the aging of the population," Grover said.
But Dr. Mullan at George Washington University says the growth of residencies is on track to meet demand from graduates of U.S. medical schools. As to whether that's enough to meet demand from foreign-trained doctors, he argues that creating more residencies to accommodate doctors who may have made a bad bet coming to the U.S. would be a bad idea.
"The notion that somehow we're deficient because we don't give them a residency is not fine,” Mullan said. "The number of residencies we ought to have in some way ought to correspond to the number of doctors we need, not the number of people in the world who want to be doctors."
Moradi, the Iranian doctor still struggling to get a residency, says she's applied to roughly 300 residency programs over the last five years. And her family is banking on her getting a match — failure to do so could mean they return to Iran. Moradi says she's willing to accept that because it also means returning to medicine.
"I'm an American," Moradi said in the backyard of her house in Malden. "This is my country too. But yes, unfortunately, I came to the point of thinking that this year if I don't get matched, I might go to Iran."
This segment aired on October 3, 2016.