Before Mervat Lotfalla immigrated to the United States eight years ago, she spent more than 15 years working as a doctor at various hospitals in Egypt.
In that period, Lotfalla — who graduated from Cairo University School of Medicine in 1994 — served as the head of Mallawy General Hospital’s emergency department, leading hundreds of staffers to provide adequate health services for rural communities there.
Then in 2009, as political unrest started brewing in her homeland, Lotfalla and her family left Egypt and established a new life in Minnesota, where she hoped to continue her career in medicine.
A year later, she began the process to get her license to practice medicine in the U.S. She passed all the examinations, but when she applied to get into a medical residency, the hands-on clinical practice experience that doctors must undergo to obtain their licenses, “I didn’t get interviews,” she said.
Lotfalla is one of many foreign-trained immigrant and refugee physicians who often struggle to put their decades-long experience to use — even as many parts of Minnesota face a shortage for doctors.
To remedy that shortage — and to address some of the barriers that prevent foreign-trained physicians from re-entering their profession — in 2015 the state of Minnesota implemented the International Medical Graduate (IMG) Assistance Program.
Housed in the Minnesota Department of Health, the IMG Assistance Program has attracted praise from many different corners, including members of the local immigrant and refugee communities and even the White House Task Force on New Americans, which recently recognized the initiative as the first state in the nation to “implement a comprehensive program.”
Indeed, the scope of the services offering through the program is impressive. Qualified participants receive assistance in career planning and exam preparation, help navigating the licensing system as well as residency placement and even financial support during the process.
There’s just one problem: When it comes to the most critical aspect of the process — placing participants into residency programs — the International Medical Graduate Assistance Program is only able to fund 1-2 participants each year.
How it works
To qualify for the IMG Assistance Program, participants must be legal residents who have lived in Minnesota for at least two years, graduated from an accredited medical school outside the U.S. and are willing to practice primary care in the state’s underserved communities in rural and urban areas.
In collaboration with Women’s Initiative for Self Empowerment, New American Alliance for Development and Workforce Development Inc., the IMG Assistance Program services a total of nearly 150 foreign-trained immigrant and refugee physicians in the Twin Cities and Rochester.
Through these organizations, participates get free access to career guidance, assistance studying for the multiple medical licensing exams as well as support in applying for medical residency programs. For those who need to improve their English or enhance their technology skills, the program also provides additional courses in medical language proficiency, “accent modification” training and electronic medical record training. Furthermore, the IMG Assistance Program also exposes its participants to alternative career pathways, such as physician assistant positions, a role that doesn’t exist in many countries.
The initiative also provides financial assistance to participants experiencing unexpected personal problems while preparing for the exams. “If someone is studying for the exam and their car breaks down, we would help them with the car situation, depending on their income level,” Anderson said. “We want them to be able to focus on the exams.”
When participants pass all their exams, the program is also able to place participants into medical residency programs, in which prospective doctors work in hospitals or clinics under an attending physician, a requirement for obtaining a license to practice medicine in the U.S.
The number of people the program can fund depends, of course, on how much money the state allocates in supporting the program, said Yende Anderson, coordinator of the IMG Assistance Program. Right now, it runs on annual budget of about $1 million. But because the cost of residency positions is so high — the average cost of a single position in primary care costs around $350,000 a year — the state is severely limited in the number of people it can place, which is why only seven people have been able to do so in the four years the program has existed.
For some, those numbers are particularly problematic given the state’s looming physician shortage. Minnesota is projected to need 2,000 primary care physicians over the next seven years, a situation born of population growth and increasing number of baby boomer doctors leaving the workforce for retirement.
“If we really do value addressing some of the health disparities that we see throughout the state,” said state Rep. Fue Lee, the program should place more foreign born doctors in residencies. “We should invest a little bit more into the program so that we could help train these professionals.”
Seeking additional funding
While the state funds only 1-2 residency positions, the IMG Assistance Program has also been working with other institutions — including Fairview Hospital, the University of Minnesota and Hennepin County Medical Center — to secure residency spots that they don’t have to pay for directly.
So far, the organization has been able to place an additional 33 applicants that way, and Anderson says that she is continually working with residency program directors to help more participants find residency positions in Minnesota. “We need to reach out to program directors and let them know what we’re doing and … how we’re helping residents to be residency-ready so that we can increase the number of residents.”
In addition to finding alternative approaches to stretch their funding, Anderson and her team at MDH are also in conversation with the Board of Medical Practice and other stakeholders in order relax some of the licensing requirements for immigrant and refugee doctors.
One of their recommendations, for example, includes eliminating the required residency training for highly experienced immigrant and refugee physicians. Instead, the department has proposed that foreign-trained doctors — after they pass all their licensing exams — demonstrate they have at least seven years of medical practice experience.
They would then participate in a six-month clinical experience in the place of a three-year residency. Afterward, they would be assessed and awarded “a certificate of clinical readiness to practice medicine” to work under supervision.
Eliminating the traditional residency program for experienced foreign-trained physicians has two main benefits, as noted in a 2017 report by MDH. First, it would help qualified physicians get into the workforce faster. Second, it would save the IMG Assistance Program hundreds of thousands of dollars that now go toward residency programs.
But not everyone thinks that’s such a great idea. The Minnesota Medical Association — which represents physicians, residents and medical students in Minnesota — opposes any change that would treat foreign-trained doctors differently than their counterparts in the U.S.
Dan Hauser, the association’s spokesman, said that it’s not fair that newly arrived immigrant doctors are allowed to skip steps that American physicians are required to undergo. “While we want to make sure we utilize all foreign-trained doctors to address workforce shortages, we do not support reducing the minimum standards of graduating from an accredited residency program,” Hauser added. “The focus must be on preparing [them] to qualify for residency to receive the needed training.”
Some of these foreign-born physicians do in fact need that training, which is the reason they’re enrolled in the IMG Assistance Program. But there are others — like Lotfalla — who have qualified for a residency but still couldn’t secure a spot.
The MDH report highlights a couple of explanations why it’s often so difficult for foreign-born doctors to secure positions in medical residency programs. First, there are a limited number of slots. Second, many residency programs only consider those who graduated from medical school within the last 3-5 years — which automatically disqualifies many older foreign-trained physicians.
That’s what happened to Lotfalla, who wasn’t accepted to a single residency program when she applied in 2011. “When I asked why,” she noted, “they said ‘Oh, the old graduation date is your problem.’”
To upgrade her classroom experience, Lotfalla left for All Saints University School of Medicine in Dominica in 2014 to take a few more courses and train to become a pediatrician.
When she graduated again in 2016, she once again applied for residency at several programs in Minnesota — to no avail. Today, she works as a freelance medical interpreter, bouncing from one hospital to another, helping Arabic-speaking patients.
She still hasn’t given up her dream, though. When she’s not working, Lotfalla is involved in the New American Alliance for Development (NAAD), a partner of the IMG Assistance Program, to keep tabs on any developments that might benefit foreign-born doctors like herself. “I hope NAAD helps every one of us to get into practicing medicine in Minnesota,” she said.