Immigrant Doctors

by on March 7, 2017 at 9:01 am in Uncategorized | Permalink

One percent of all the physicians in the United States come from the six countries targeted in Donald Trump’s new Executive Order. I found that a surprisingly high number. According to the Immigrant Doctors Project, those 7000 physicians provide 14 million doctors’ appointments each year and many of them are located in the poorer, whiter, and rural parts of the country.

I don’t see this as a knockdown argument against the policy but it does illustrate a surprising cost and also how much the United States benefits from the immigration of the highly-skilled and educated.

1 V March 7, 2017 at 9:15 am

Couldn’t it also be possible that the presence of a large number of immigrant doctors show any number of other outcomes e.g.,
1) our current medical education policy is too restrictive towards domestic aspiring doctors who might be able to easily fill any “gap” that exists
2) importing large numbers of foreign doctors depresses wages and / or lowers quality in appreciable ways
3) this importation creates massive costs for the source nations (who can ill-afford these costs) and harms longer-term growth in those nations
etc.

It may be the case that none of the above is true or a significant concern but think they at least merit concern

2 dan1111 March 7, 2017 at 9:39 am

American doctors are some of the highest paid in the world, one important reason why health care in the USA is so expensive.

Barriers to entry in the profession are also, not coincidentally, some of the world’s highest. In particular, it is very difficult for foreign trained medics to enter the system, compared to most other developed nations.

In other words, that might be a valid hypothetical in the abstract, but it certainly doesn’t apply to the reality in the ground in this case.

3 Jasy March 7, 2017 at 10:32 am

Doctors’ wages account for a pretty small percentage of total health care costs.

4 Jan March 7, 2017 at 11:00 am

About 20 percent of total national health spending?

5 Troll me March 7, 2017 at 12:28 pm

Less than spent on military?

6 V March 7, 2017 at 1:02 pm

Jan — that 20% number is not wages but instead a gross amount paid into any provider of which labor costs (not just physicians) are one component.

Dan1111– if you look at much poorer nations like India or middle-income ones like Mexico, you also see very long paths for medical education / training. While a barrier to entry, much more likely to be necessary to attain some skill or minimum level of quality in the field rather than some sinister plot to raise wages. In terms of entry for foreign docs, the US has one of the highest percentages of foreign doctors depending on peer set chosen so not sure which data source you are using

Anyway, all of above is irrelevant as the point I was making about Tabarrok is that he isn’t even attempting to state what his assumptions are for thinking that this random flow of labor is a benefit to the country rather than just a result of path-dependence

7 Jan March 7, 2017 at 5:57 pm

V, thanks.

8 lol March 10, 2017 at 11:52 pm

@V: It’s the other way around. Indian high school and med school are so short, some the interviewees for residency jobs are still under age for alcohol. This is one of the reasons US is flooded with Indian, rather than Chinese, doctors.

9 msgkings March 7, 2017 at 1:03 pm

How about all the income docs get referring patients to clinics and testing centers they own? Doesn’t show up as salary.

10 Jan March 7, 2017 at 10:58 am

Yup. There are a few different reasons that health care is so outrageously expensive in the US.

Perhaps the easiest to fix is the fact that docs are overpaid compared to their education and expertise, mainly because physician orgs are extremely effectively in lobbying for policies that ensure an artificially low supply of doctors.

11 NatashaRostova March 7, 2017 at 11:08 am

The idea that doctors are overpaid is a meme. If you actually look at the ability they must possess, the years of training, the cost of tuition, and the inherent stress of the job, it’s challenging to say they are overpaid.

But my response perhaps misses a higher dimensional point we could both agree on.

If the government said “you may only buy very safe cars, such as a Volvo, which tend to cost at minimum $35,000 a year” this wouldn’t mean the Volvo costs too much, as it’s still a great car. However, it might mean we observe inefficient outcomes as your risk preference and endowment means you would rather trade some safety for a $20,000 car.

Similarly, a poorer person may be willing to risk having a nurse diagnose them, knowing the nurse lacks training, but at 1/5th the cost.

Doctors themselves though really aren’t overpaid when you look at their input requirements. Granted, what overpaid means has no meaningful economic definition except when we know the market clearing price and can explicitly see the price is higher than this. Anecdotally though all my brilliant friends and family who became doctors allowed their peers to blow past them in far more lucrative fields, while they were still living poor and overworked with immense stress and massive debt while in residency in their early 30s

12 Doug March 7, 2017 at 11:34 am

“f you actually look at the ability they must possess, the years of training, the cost of tuition, and the inherent stress of the job, it’s challenging to say they are overpaid.”

I think the point is the amount of training doctors are required to have is overkill. Resulting in artificial restriction of supply. Let’s be real: the guy who’s job is to write pimple and eczema prescriptions probably doesn’t need years of organic chemistry and physics.

13 Jan March 7, 2017 at 11:41 am

While I would love to make a meme out of this, I think your argument is pretty clearly wrong. Primary care docs are probably making the right amount. US specialists, after taking into account their education, debt, etc make much, much more than their colleagues on other rich countries. And there is no evidence that American docs on average provide much better care than docs in other wealthy countries.

14 Cooper March 7, 2017 at 1:01 pm

Compare the salaries of American doctors to the salaries of French, Canadian, German and Dutch doctors.

Now compare the inputs.

Still think American doctors aren’t overpaid?

15 Thomas March 7, 2017 at 1:06 pm

Do US doctors make a higher wage premium over foreign counterparts than humanities professors, stockbrokers, or journalists? If so are you willing to open up supply by reducing regulatory requirements, or are you simply going to demand lower prices at the barrel of a gun, soothing your inner bolshevik? If the latter, will there be an “individual mandate” to require all doctors practice?

16 Bob from Ohio March 7, 2017 at 2:19 pm

“Do US doctors make a higher wage premium over foreign counterparts than humanities professors, stockbrokers, or journalists? ”

Or athletes or actors or steel workers or lawyers or …

Amazing the experts on the Just Right wages of doctors posting here.

17 Thomas March 7, 2017 at 2:45 pm

1. Be the top 1% academically with a focus on science

2. Score extremely well to below average on your SAT, depending on how much people like Jan approve of your sex and skin color.

3. Gain admission to a prestigious university

4. Matriculate with a very high GPA

5. Score extremely well to below average on the MCAT, depending on how much people like Jan approve of your sex and skin color.

6. Study 40-60 hours per week for 3 years to pass med school.

7. Match a residency based a combination of your medical school rank and how much people like Jan approve of your sex and skin color.

8. Be castigated by people like Jan for being paid commensurate to your immense skill, the rarity of your skill, the time and brainpower you invested, and the gauntlet of selectivity you endured.

9. Juxtapose your 1% IQ, ultra rare skill, $300,000 debt, $500,000 income, 13 years of college, med school, residency, fellowship, specialization, and 60 hour work weeks against the 60% IQ, “skill”, $20,000 debt, $80,000 income, 4 years of college, and 30 hour annualized work week of Chicago Public School teachers lionized by people like Jan.

10. Vote Republican

18 Rick Zhang March 7, 2017 at 3:12 pm

Except it’s now a $400,000-$500,000 debt (for Caribbean and DO grads) with $200,000-$300,000 income. I recently oversaw a medical student who, with his spouse, had a combined $1 million in student loans from undergrad and med school.

19 So Much For Subtlety March 7, 2017 at 6:00 pm

Thomas March 7, 2017 at 2:45 pm

1. Be the top 1% academically with a focus on science
….
9. Juxtapose your 1% IQ, ultra rare skill, $300,000 debt, $500,000 income, 13 years of college, med school, residency, fellowship, specialization, and 60 hour work weeks against the 60% IQ, “skill”, $20,000 debt, $80,000 income, 4 years of college, and 30 hour annualized work week of Chicago Public School teachers lionized by people like Jan.

10. Vote Republican

Don’t forget,

11. Spend all your time in low-level work such handing out aspirin and giving ‘flu shots that any High School drop out could do.

There was a time when doctors did everything – emergency surgery, births, autopsies and so on. But those days have gone. If anyone shows any signs of anything complicated, they are sent to a real hospital or to a specialist. What most GPs do is utterly boring, routine work that could be done by a nurse.

One of the bizarre things about the modern West is that we take the top 1%, give them years and years of training at enormous cost and then expect them to do the most routine, undemanding. mundane work around. Working in a factory is a lot more intellectual challenging. My GP is a very nice girl but she googles my symptoms. Good thing to see all that education paying off.

20 Jan March 7, 2017 at 6:02 pm

Doctors are overpaid. It is not even close to other countries for specialists, which are now the majority of physicians.

You can try to justify their outrageous salaries (e.g. debt, imputed IQ), but that is not an approach you take to justifiy the salaries of any other profession. It is especially rich coming from Rich.

And yes, I think this disparity between US salaries and other countries is an outlier among professions.

Thomas, if you think docs are being paid commensurate to skill rather than commensurate to their lobbying power and the fact that Medicare prices are set by a board of mainly specialty physicians, you don’t know how this country works.

21 Jan March 7, 2017 at 6:03 pm

Typo. Should read “It is especially rich coming from Thomas”.

22 Thomas March 7, 2017 at 7:52 pm

I do not support the AMA or most regulatory burdens to entry, Jan. Can you say the same? You are the party of barber licenses afterall.

23 Larry Siegel March 8, 2017 at 3:58 am

>the guy who’s job is to write pimple and eczema prescriptions probably doesn’t need years of organic chemistry and physics.

Seriously? Yes, he does. If my dermatologist misses a melanoma, I die. There are a lot of skin diseases that involve complex treatments. And dermatologists also practice a lot of general medicine, so he needs to know roughly what a GP knows.

24 lol March 10, 2017 at 11:54 pm

@Cooper: You forgot Canadian and Australian docs. Also, compare their results.

25 JWatts March 7, 2017 at 11:13 am

Yes, American Doctors have a very high compensation rate. There aren’t a whole lot of paths to cheaper US healthcare that don’t involve Doctors making less money as a group. I suspect the eventual path will involve automation. Sophisticated devices that reduce the amount of time that doctors spend per patient, thus lowering the number of Doctors needed.

26 Mark B March 7, 2017 at 11:44 am

Excellent point! I can easily envision a simple adaptive questionnaire that takes 5-10 minutes and provides a lot of information to the doctor before the actual interaction. Maybe even voice recognition for patients with “challenges”. This could lead to better records and shorter appointments. Current systems feel insanely inefficient.

27 Potato March 7, 2017 at 11:45 pm

Apparently it’s Opposite Day. Jan is arguing that government restrictions cause increasing costs. Others are arguing it’s their inherent supremacy that causes their wage. This is republican/democrat vs Russia levels of 180 degrees.

Anyways, this to me is an example of 2 things. One is klings explanation of subsidizing demand and restricting supply, which is the go to government response. And incredibly stupid.

The second is the managerial class preference of: free trade for thee, but not for me. Lower classes get direct competition, The mandarin class builds certification walls and a powerful lobby to protect it. The AMA is basically a union. I find it hard to believe there are people on MR comments arguing in favor of it, where Jan is the voice of reason.

I apologize to Jan. I may disagree with him on almost everything, but he is clearly closer to the truth on this issue. And I shouldnt rush to judgement.

Sorry Jan

28 Boonton March 7, 2017 at 4:26 pm

It is indeed true doctors are well paid. But from what I see of the health system there’s a huge number of people much less well paid. At both the local doctor’s office and at a huge regional academic center, what I see is that everything that can be done by a lower paid person is done. When you walk in a low paid greeter puts you in the computer. Simple vitals like BP, temperature and weight are done not by a nurse but an assistant. If you need blood drawn, that too is not done by the doctor or nurse but by a phlebotomist. Paperwork, billing, insurance verification etc. are all done by lower paid office staff. There’s no doubt a lot I don’t see like the doctor’s verbal notes being transcribed by computer or low paid person overseas….the reports written by experts in India rather than the US.

To me it seems like a machine designed to ensure the high paid doctor never does anything that couldn’t be outsourced to someone less paid. As a result the doctor probably doesn’t feel like he is collecting monopoly rents but in fact probably is under as much pressure to always be consulting with patients, always trying to do as many billable ‘appointments’ in an hour as he can.

What this tells me is that doctor pay is probably not a huge factor in health cost. If it was doctor’s would see their standards of living rising higher and higher relative to doctors in the past and others in the economy yet many probably feel the opposite.

29 Larry Siegel March 8, 2017 at 3:58 am

You nailed it.

30 lambert March 7, 2017 at 9:52 am

“….our current medical education policy {government regulation} is too restrictive..”

An understatement.

Why should a huge, wealthy, advanced nation like the U.S. have even the slightest dependency upon immigrant physicians (from anywhere) ?

The answer, of course, is that U.S. federal/state government has artificially restricted the supply of licensed physicians and health care workers generally… for a century.

What possible solution might there be to this artificial economic problem?

31 Thiago Ribeiro March 7, 2017 at 11:12 am

It must be kept in mind that the American educational system can not anymore provide some kinds of expertise in the numbers they are needed by a complex and affluent society. By the way, it was one of the themes of Rising Sun by Mr. Crichton. One just have to visit any American lab or Silicon Valley to see that.

32 JWatts March 7, 2017 at 11:23 am

“It must be kept in mind that the American educational system can not anymore provide some kinds of expertise in the numbers they are needed by a complex and affluent society.”

Actually the American educational system provides more expertise in greater numbers than the US utilizes. Hence, America educates far more college students, particularly advanced degrees than it employees.

” One just have to visit any American lab or Silicon Valley to see that.”

The majority of those people have degrees from an American university.

33 Mark B March 7, 2017 at 11:47 am

Most college graduates are very poorly prepared for any sort of technical work, especially in medicine. You are seriously proposing that visual arts majors will become doctors ( in significant numbers)?

34 JWatts March 7, 2017 at 2:38 pm

“Most college graduates are very poorly prepared for any sort of technical work, especially in medicine. You are seriously proposing that visual arts majors will become doctors ( in significant numbers)?”

The US graduates around 300,000 STEM majors per year. The US graduates about 19,000 physicians per year. There’s plenty of room to increase the number of physicians without plumbing the depths of the basket weaving degrees.

35 Bob March 7, 2017 at 11:58 am

In the case of SV, it’s hard to blame the education system being too expensive or full of red tape: There is zero regulation, and CS is a regular 4 year degree: Lots of physicists, biologists and even aerospace engineers that took CS oriented classes look at the job market and migrating to software.

On this, I think we have a visibility problem: Young adults entering college don’t have a very good idea of the economic outcomes of their educational choices. How much does the degree cost? How many people graduate? What is the income distribution after finishing? How many people get a job in major? With that data, I’d be surprised if we kept seeing so many people walking on the meat grinder that is experimental science, and we’d see more people in the parts of STEM that lead to jobs.

Doctors, on the other hand, has a lot to do with how most of the rest of the world heavily subsidizes their education, while the US does not. Entering medical school is very hard and very expensive. It should be cheaper and easier to get in, making the real limitation whether someone wants to put the crazy amount of work to takes getting past schooling and the residency.

36 Troll me March 7, 2017 at 12:32 pm

Maybe they are attracted by higher salaries and the extent of barriers are still insufficient to completely block access to this additional supply?

37 Rick Zhang March 7, 2017 at 2:23 pm

Reading through these comments it’s striking to me how laughably ignorant most people are on how the health care system (and particularly medical education) functions. Fact: I am a practicing physician, and I have been on the teams in charge of certifying medical schools, so I have some insider knowledge of what goes on in med school and residency.

Are physicians overpaid? This is a complicated question. One can argue that the market is setting the wage and the paucity of residency spots (not med school spots) is the bottleneck that artificially boosts the wage. Who can you blame for this? Congress is one place to start as they are the ones who limit the Medicare funding that pays residents. That’s always been an oddity to me. Why not just let residents bill at 50% of full physician pay (NPs and PAs can already do so at 60-80%, with less training) so they can become an asset rather than a liability to their hospitals? Then see the number of residency spots skyrocket.

I’m not sure you can bring the AMA into this as despite their lobbying efforts they represent a minority of physicians (and mostly specialists). Those of us on the ground would actually want some additional help. Unlike other professions, in medicine you have an unpredictable amount of work spread out over a constant number of people. Let’s say there’s a dramatic unpredictable rise in the number of patients entering the ER. You as a working doc will be told to see more, do more, be more efficient, etc. to manage a 50% spike in individual workload. If you can cope and maintain your sanity, you’ll burn out within 5-10 years. Most of us would appreciate having an extra colleague with whom to share the workload.

Even if you just look at international comparisons that show American doctors as the most well-compensated in the field, they fail to factor in malpractice premium and education costs (both in years and money). You need to pay US grads a certain level that lets them have a chance at repaying those loans. Furthermore, part of the premium is due to the high inequality and high compensation of other professionals (law, banking, consulting). Medicine needs to be roughly comparable to these in order to attract enough applicants. In France, if you have few other lucrative career options (big productive multinational, civil service?), medicine looks good in comparison, with a big wage premium over comparable work.

Another tidbit (tangential to the above discussion) is the geographic inequality in pay. Medicare reimburses roughly the same regardless of whether you’re in San Francisco or Omaha. Despite the obvious cost of living difference, physicians still choose to live in large coastal cities (due to spousal jobs, cultural amenities). Here I would argue that the wage premium over a software engineer (who can earn comparable amounts with much less training and debt) is low, such that even some of my colleagues who are part of two physician families have a hard time buying a house. Unlike most other professions where there is an urban cost of living adjustment, in medicine there is an inverse incentive to work in undersupplied rural and “Heartland” locations (more in signing bonus and perks rather than pay). Despite this, US trained grads don’t go to these locations. The immigrant physician desperate for a J-1 or H-1 visa sponsor fills in the gap.

Immigrant physicians are required by the most restrictive medical practice laws in the world to redo their residency before they can practice. They are not your kids’ competition for medical school spots. They may be for residency, but there’s a huge bias in favour of domestic grads when matching for residency. Though, similar to many other fields (such as agriculture), there don’t seem to be Americans interested in working some of these jobs. The insider scoop is that starting 5 years ago, Nephrology as a field started filling only about 50% of its fellowship spots, and most of those are internationally-trained physicians, leaving a huge shortage that will manifest itself in the next decade. Literally you can walk in off the street and claim a formerly prestigious Nephrology fellowship spot at UCLA of all places! Professional societies fret and theorize all sorts of insane explanations. To those of us on the ground, the underlying reason is obvious – why spend 3 years earning low income in fellowship only to emerge less employable and with a worse work lifestyle to boot?

I will agree with some other commentators that the medical education system is too long and spends too much time in general education. Reforming it by moving to a specialized 5-6 year MBBS degree straight out of high school in line with other commonwealth nations is something I’ve always supported.

As the ultimate decider, you may ask what I’m recommending to young people today. I have actually been telling them that the cost/benefit trade off in medicine today is not a good one. The training is too long and expensive. It’s also grueling – meaning you’ll spend your best years (20s) trapped in the dungeon of the school library. You’ll make enough to live a comfortable middle class life but always under the threat of one of the above reforms cutting into your income or lifestyle. It’s far better (and more profitable) to go into banking, CS, or even nursing. CS in the bay makes a comparable income, and nursing gets you a 3 day work week with $100k+ salary (in California only) after only a 2 year degree. if you truly like “medicine”, become a nurse practitioner or physician assistant and have more authority in much shorter time. If you absolute must become a doctor, get a subsidized degree overseas and return to the US for residency younger and in less debt than your peers.

38 Terd Ferguson March 7, 2017 at 2:30 pm

Interesting point with the J1 visa. Once it expires (end of residency) you have to return to your home country for 3 years before you can reenter under the H1 visa program UNLESS you work at an under served area. Just so happens the majority of under served areas are poorer, whiter, and rural parts of the country. So correlation/causation?

http://www.immigration.com/j-1-visa-waivers-physicians-work-medically-underserved-areas

39 Rick Zhang March 7, 2017 at 2:41 pm

Exactly. Anecdotally that’s what I see as well. I know many immigrant doctors (often from Pakistan/India) who are in Neurosurgery training now who originally “did their time” in North Dakota or inner city Philly.

40 Potato March 7, 2017 at 11:56 pm

Rick,

Great post, I only have one quibble.

Medicine does not need to be nearly as lucrative as banking, consulting, or elite law. There is no artificial bottleneck for the other jobs. They take as many as they need for their business, which is based in signaling to customers that they have the most elite people. As someone who’s worked in one of those industries, it is a much different set of hoops we go through to hire. If they’re not Ivy League or one of those other schools: Claremont, Middlebury, there’s like one or two more, we throw their resume in the trash. But that’s an economic theory: customer based discrimination, which is well documented in theory and practice; customers demand a certain thing (prestige) and the hiring adapts to this.

There’s no credential. There’s no consulting review board. It’s hey, will this dude add to our prestige or take away from it. Medicine is : is he certified ?

We’ve created a cartel, and yes they’re overpaid. The question isn’t can they meet the barrier and jump, the question is , for most of the work can someone else do it.

41 NatashaRostova March 7, 2017 at 2:36 pm

Agree on all points, to add to your last one, anyone who actually has a friend/family group that consists of both CS and Doctor types knows the CS guys have cushier lives, and while lifetime income might be the same, they get to enjoy money and free-time in their 20s and 30s, whereas Doctors don’t.

I have friends who went to Stanford (I didn’t), some of whom did CS other Medicine. The medicine guys are toiling for 60k residency jobs at age 30. The CS guy are millionaires.

42 Rick Zhang March 7, 2017 at 2:39 pm

For full disclose I actually have both a CS degree and a medicine degree. I’m also working on a variety of startup ideas so I may eventually leave medicine one of these years.

43 Anoni March 7, 2017 at 3:56 pm

This just enrages me, Cowens post and the facts. I have quite smart students who can’t get into med school in the U.S., who I am sure would be better than thse immigrants. Using immigrants to justify the ridiculous regulatory barriers facing people who are not the children of Cowen’s friends is just despicable.

There are a ton of Western VA kids like this and its clear that Cowen hates every one of them. He should move to Somalia and help out there directly.

44 tony cohen March 7, 2017 at 5:19 pm

You must have amazing powers to only have met one out of a pair and already know which is better. How did you get that deductive power?

45 education realist March 7, 2017 at 9:16 am

Totally fine with fewer immigrant doctors. At this point, the doctors in my area (the opposite of poor) are overwhelmingly immigrant. Meanwhile, med school here gets more and more competitive.

Obvious solution is not more immigration.

46 Ted Craig March 7, 2017 at 9:21 am

I’m not opposed at all to immigrant doctors, but yes, there are solutions such as expanding med school enrollment. And before anybody says that would lower the quality of doctors, I’m not sure it would. My experience, which consists of watching people try to get into med school, is that it’s overly selective in the U.S.

47 dan1111 March 7, 2017 at 9:42 am

Making med school less exclusive would increase the supply of doctors, allowing more competition and discretion in hiring.

This has to be weighed against any negative effect of lowering the bar.

48 Jasy March 7, 2017 at 10:38 am

DO schools have made an increasingly important contribution to the physician workforce and those schools are not particularly difficult to get into.

The problem is that residency spots are limited. We are currently turning out more graduates than there are residency spots to accept them. The solution is to increase funding for residency (their salaries are paid by Medicare).

49 Bob from Ohio March 7, 2017 at 2:09 pm

“Obvious solution is not more immigration.”

To reasonable people perhaps, not to open border fanatics like AT.

50 Art Deco March 7, 2017 at 9:28 am

how much the United States benefits from the immigration of the highly-skilled and educated.

The benefit in this case would be the surplus derived from outsourcing the training of about 240 physicians from each annual cohort licensed. Likely pretty minimal.

51 Thiago Ribeiro March 7, 2017 at 11:15 am

From only six countries. Even if immigrants from those cou tries are to be banned due to security issues, the simple dfact bears witness to how much Americans profit from immigration.

52 EH March 7, 2017 at 9:37 am

If we started requiring U.S. medical schools to enroll at least 90% of U.S. citizens in order to retain federal funding–which is to say, if we stopped using our scare and expensive resource to train people for working elsewhere–then we’d have more American doctors. (The same applies to PhD programs, though that’s a different conversation.)

Similarly, if we created more lower-tier medical schools in the U.S. we would also fill that gap. After all, if we’re willing to give credentials to folks from other countries who have lower admission standards, why don’t we offer those standards here?

53 Jasy March 7, 2017 at 10:41 am

There are plenty of low tier medical schools in the US. They are called osteopathic (DO) schools. The problem is that there are not enough residency positions to accept the graduates.

54 Troll me March 7, 2017 at 12:35 pm

Foreigners do not get free education the US (exceptions for top performers in various fields), which by the way has some of the most expensive education around.

55 Andrew M March 7, 2017 at 9:41 am

This is a classic bait-and-switch. “Hey look at how great immigrants are! They’re all hard-working doctors and PhD-qualified scientists.” Sounds great, so we accept the bait. Then they switch the product, and we end up with taxi drivers and food service workers.

On an unrelated point, how easy and/or cheap would it be for a U.S. kid to enroll in med school somewhere like India? When they graduate, would their overseas qualifications be automatically accepted back home, or are there more barriers to overcome before they can practice in the U.S.?

56 dan1111 March 7, 2017 at 9:45 am

Barriers to entry in the US are huge. Most countries accept foreign trained doctors on the basis of passing exams, but in the US you have to go through the whole multi-year residency process.

57 Joe In Morgantown March 7, 2017 at 11:36 am

A fair number of Americans do go abroad to study medicine. I think it is more typically the West Indies instead of India.

Granada’s sgu.edu claims to be the largest provider of medical doctors to America in the the world.

58 Dan Hill March 7, 2017 at 5:27 pm

Andrew M – what do you have against taxi drivers and food service workers? Damn immigrants, coming here and being productive members of society, providing services to Americans…

59 Chip March 7, 2017 at 9:58 am

“I don’t see this as a knockdown argument against the policy but it does illustrate a surprising cost and also how much the United States benefits from the immigration of the highly-skilled and educated.”

And yet US immigration policy is now dominated by flows of unskilled workers. In Germany, where a recent influx is from the same countries included in the temporary travel ban, only 13% have found jobs.

Concerns over immigration don’t arise from the arrival of skilled professionals.

60 Axa March 7, 2017 at 11:08 am

Concerns don’t arise from foreign skilled professionals, but the consequences of acting from said concerns affects foreign skilled professionals. In more simple words: sloppy policy implementation.

61 Troll me March 7, 2017 at 12:46 pm

Aren’t they disallowed from looking for work during an initial period after a refugee application is accepted and being processed?

The 13% figure would be very misleading for reasons like that.

62 Li Zhi March 7, 2017 at 10:06 am

Those 6 countries account for ~ 2.5% of world population (although South Sudan is probably mixed in with Sudan since they used a doctors’ medical school as his/her emigration country). WHO ranks the health care systems of the relevant countries as follows USA 37th, Libya 87th, Iran 93rd, Syria 108th, Yemen 120th, Sudan 134th, & Somalia 179th (out of 190). So, we should be a bit dubious about whether these doctors improve our system, depending on the relationship between a country’s health care and their medical schools. Iran has 1.1% of world population, Sudan 0.6 & Yemen 0.4 so you wouldn’t expect the bulk of these doctors to be in the upper half of any medical competence scale, especially given probable language/communication problems. OTOH, I’m good with us stealing other countries’ best and brightest, regardless of their training. Of course, I don’t know how stringent these countries’ medical school entrance requirements are… Yeah, I think AT’s OP is pretty much unhelpful. Why would anyone be surprised that the USA, with grossly overpaid doctors (relative to the rest of the world) attracts a disproportionate number of medically trained immigrants?

63 commentariette March 7, 2017 at 10:36 am

I’m not sure these numbers pass a sanity check. Note that they come from an advocacy group “Immigrant Doctors Project”.

The six countries are ~2.5% of the world population. In three of them, between one- and two-thirds of the female population is illiterate (though male literacy is somewhat higher). A couple of these countries haven’t had a functioning government in decades. Only Iran has a substantially functioning system of higher education (and until recently Syria and maybe Libya to some extent). Countries that are culturally or geographically closer, such as the Gulf States or Europe, would also be attractive to iimmigrants.

I suppose it’s possible, but it seems implausible that these countries are able to produce such a large stream of qualified physicians immigrating to the US. I’d try to find some independent confirmation of those figures….

64 sort_of_knowledgeable March 7, 2017 at 11:36 am

7000 immigrating over 30 years seems reasonable, especially when the countries were more stable. I imagine there might have been number of Syrian doctors who left a few years ago when they sensed things were about to go to hell. The question of how many potential doctors are being cut off now is a different question.

65 Joël March 7, 2017 at 12:22 pm

Have anyone seen on the Immigrant Doctors Project’s website the number of immigrant doctors by countries, for each of the six? I would imagine that the large majority of them would come from Iran, plus perhaps a few from Syria, and near zero from the others.

66 Troll me March 7, 2017 at 12:51 pm

My guess it that the median doctor in those countries doesn’t have much of a chance of becoming a doctor in the US, for practical puporses considering language barriers and reduced prior training.

67 Barkley Rosser March 7, 2017 at 10:26 am

The AMA is very powerful, and everybody from the late Milton Friedman to Dean Baker has pointed this out. In fact, immingration restrictions for health care personnel were tightened during the Clinton administration with little commentary on this at the time. Baker has been pounding relentlessly on how our tight immigration restrictions have helped push up medical care costs in the US, with those far higher than anywhere else with little evidence of better care resulting, and our physicians also paid way more than elsewhere.

Sure, we should have more med schools and residencies, blah blah blah. But loosening our stupid immigration rules in this area would be a quick and easy way to help out our problems in this area, but the AMA is so powerful I never once saw any politician from either party suggest doing this during the debate over ACA initially or now. Instead, we have this further tightening of immigration, although it is not directed specifically at physicians.

68 VD March 7, 2017 at 11:49 am

Residencies are the rate limiting step. Foreign physicians are not legally allowed to practice in the united states, even if they have completed all schooling, ‘residency,’ and certifications overseas. Foreign physicians must be involved in graduate medical education (residency) in some way before they can legally practice. Immigration of foreign physicians actually isn’t a problem, it’s that there are limited residency slots.

69 John Mansfield March 7, 2017 at 10:28 am

Existing medical schools have reasons for not expanding enrollment, so it makes me wonder what it takes to start a new medical school. I see that the UNLV medical school will start educating its first class of 60 students this year. The link below shows various milestones of the last few years such as: hiring a dean in May 2014, starting an 18-month accreditation process in November 2014, funding of $27 million from the legislature in June 2015. None of the work seems outlandishly difficult (or unnecessarily burdensome) if some body desires to create a medical school.

One of the milestones from June 2015: “The Founding Scholarship campaign wraps up in less than 60 days with $13.5 million to secure 135, four-year student scholarships — 60 for the charter class, and 25 each for the next three consecutive classes.”

http://www.unlv.edu/medicine/milestones

70 Anon March 7, 2017 at 10:31 am

After the million-plus Middle Eastern migrants complete their advanced medical studies in Germany, think of how much better off native Germans will be.

71 Protagoras March 7, 2017 at 10:37 am

I’m not really surprised, with Iran being one of the countries on the list. I suppose any actual doctors who fled at the time of the fall of the Shah would probably be retired by now, but children who fled with their parents would be the right age to be practicing, and given the kind of people who would have been the ones to flee, I’d expect a lot of those to be educated and have made their way into professions like medicine.

72 GoneWithTheWind March 7, 2017 at 10:47 am

Do you believe that Americans couldn’t do this? Medical colleges accept a certain percentage of foreign students which means that these institutions supported by our tax dollars must prevent an American student from being selected for that highly sought after slot. Wouldn’t a better solution be to require American colleges to enroll Americans and then we wouldn’t be dependent on foreign immigrant doctors???

73 Thiago Ribeiro March 7, 2017 at 11:20 am

I guess America always can use another affirmative action programme.

74 Troll me March 7, 2017 at 12:56 pm

So you want foreign doctors to pay a premium for access to medical training in the US AND also poach doctors from their countries?

You know, sometimes I wonder what percentage of Americans have ever encountered the concept of reciprocity outside of at least maybe the guy should care if the women gets something out of sex too. Reciprocity matters.

75 Rick Zhang March 7, 2017 at 2:37 pm

But PUA literature tells us that women actually like men who are more selfish and dominant. They are the desirable “alpha” after all!

76 Troll me March 8, 2017 at 11:42 pm

Different than what I was thinking of.

And, I would like to highlight that there is nothing about dominance which suggests that you shouldn’t care if the woman gets anyhting out it.

But if I recall correctly, survey says that women like to date men like that, but marry and settle with others. Mabye in some thousands of generations that will have some effect on our warlikeness? (Better legalize rape quick, no?)

77 GoneWithTheWind March 7, 2017 at 6:34 pm

No reciprocity necessary because what I am proposing is no foreign students. Remove your biases from this equation and it makes perfect sense. American taxpayers pay for these schools and yet the administrators of the schools refuse admission every year to a certain number of Americans just so they can offer those slots to foreign students for a variety of reasons and maybe some are even good reasons at least in their own minds. But the bottom line is American taxpayers are being short changed and non-taxpaying foreign students are getting a windfall thanks to those same tax payers. My suggestion makes perfect sense.

And, by the way; don’t talk about sex again, stick to things you know something about.

78 chuck martel March 7, 2017 at 10:17 pm

US medical schools and other institutions of higher learning love foreign students because they pay the maximum rates to attend. Schools make a lot of money off of foreign students.

79 GoneWithTheWind March 8, 2017 at 12:51 am

Well yes and no. Most schools will get a substantial amount of money from government for each in state student and each in country student but not nearly as much for foreign students. So they charge the foreign student more for tuition. Theoretically it evens out But in fact the government puts strings on their money and they audit it to assure that the college follows the rules. The out of country tuition is a large pool of unregulated mmoney that finds it’s way into slush funds. Every college spends it differently but they all spend it without the meddling of federal and state government.

80 tony cohen March 7, 2017 at 5:25 pm

Do they accept or certain % or are they required to? It seems like you think the theoretical American doctors would be as good as the foreign doctors coming in.

This is total guesswork, but I am betting the immigrant Dr. who make it here are pretty darn amazing.

81 anon March 7, 2017 at 10:52 am

Step back, and look at the ban on light of other legal and social changes (including at the extreme, shootings). This is less about concrete results (jobs or terror) and more about taking in the welcome mat.

Living as you do in India now, I would expect you hear the results in daily conversation.

82 VD March 7, 2017 at 11:10 am

And yet every year here in the UT system, competent medical school graduates do not match, while we match plenty of medical school graduates from the middle east. The foreign graduates’ tests scores are not higher…so why is this happening? We had 1200 (400 or so met minimum standards) medical school graduates apply for our 11 intern slots, some 250 were from United States medical schools. Sorry Alex, you’re commenting out of your element here. Perhaps it is different in the tech sector, but we do not depend upon foreign medical graduates in any way.

83 anon March 7, 2017 at 11:12 am

Curious, 250 of the 400 is not great. 250 of the 1200 is terrible.

84 VD March 7, 2017 at 11:43 am

Our program is a competitive specialty and most UT graduate medical education (gme) locations are desirable comparable to residency sites throughout the US. 250 out of 400 is similar across gme. The family medicine residencies will frequently get 2000+ foreign applications; most family medicine residencies I’m aware of receive far more foreign applications than US applications. We also include all caribbean schools as ‘foreign.’ I’ve been doing this for four years, and I still find it astounding how many qualified USmedical school graduates there are compared to the residency slots available. The incentives between the medical schools and the residency programs are completely uncoupled, which leads to medical schools opening and expanding willy nilly, while residency slots have barely increased.

85 Rick Zhang March 7, 2017 at 2:30 pm

I’ve observed this as well. The reason is that most US grads aim to aspire “higher” and do better than to match in a podunk community FM program (as they see it). Unfortunately there’s a bit of stigma attached to these programs that’s hard to overcome. Perhaps when you reach a certain threshold of foreign grads in the program, US grads don’t even bother to apply. Cook County IM in Chicago certainly is like this. On the trail, we all knew that was the “IMG” program and we didn’t even bother to apply, even as a safety spot.

86 Quatro al Sadis March 7, 2017 at 11:17 am

Surely, if someone is a doctor, he/she is no threat at all. Just ask DOCTOR Ayman alZwahiri.

87 Troll me March 7, 2017 at 12:59 pm

We should also ban public parks because one time something bad happened in one.

88 Thomas March 7, 2017 at 2:07 pm

“I don’t understand conditional probability”

89 Troll me March 7, 2017 at 2:37 pm

Well if children never went outside, most especially to go to the park (which used to be extremely common), then fewer bad things (scrapes, perhaps, but maybe much worse) would happen.

Conditional on the existence of a park to go to where bad things might happen, relative to that benchmark there would be fewer bad things in parks by removing the parks. if there were no park then i

I’m surprised that you are aware of the existence of such a concept as conditional probability. It suggests that you’re not half the idiot you play in many other instances.

90 Thomas March 7, 2017 at 5:36 pm

What a joke. My analysis is superior to your feelings in all cases. You are repeating the idiot meme “bathtubs kill more people than…”. Bathtubs aren’t trying to kill people against the efforts of the state.

91 Troll me March 8, 2017 at 11:48 pm

Well, since YOU bring up bathtubs this time, let’s highlight the fact that it is a fact and not a “meme”.

But what does that matter in the post-truth world?

92 eded March 7, 2017 at 11:27 am

Is it ethical for wealthy countries to poach the few trained doctors that exist in poor countries?

93 Axa March 7, 2017 at 11:52 am

Assuming those doctors are licensed, they did years long residencies in the US to obtain their licenses. Salaries and indirect costs of medical residents are subsidized by Medicare, meaning payroll taxes.

So, can you call it poaching when you payed for the training of those guys during 3-6 years?

94 Lord Action March 7, 2017 at 12:26 pm

“So, can you call it poaching when you payed for the training of those guys during 3-6 years?”

I don’t actually object to poaching, but doesn’t that make it even more poaching? You not only hired these guys, you paid for a good bit of their training.

95 Troll me March 7, 2017 at 1:01 pm

No.

But for those whose job is to work for the national interest, for the benefit of citizens and the taxpayer pool, it would be unethical for them not to. Of course, since we know it’s not all peachy, they can weigh that by not trying too hard.

96 lolz March 7, 2017 at 3:48 pm

is it ethical to force doctors to practice in countries they don’t wish to?

97 Troll me March 8, 2017 at 11:53 pm

My absence of a green card does not make me a victim for being limited to the Canadian market.

As for refugees, they should be accepted on the basis of need, not profession.

98 Axa March 7, 2017 at 11:42 am

State level licensing for doctors is not optimal. What about a federal medical practitioner license? It’s not a good sign that obtaining a 2nd license in another state implies “Plan to Wait at Least 60 Days” https://www.ama-assn.org/education/obtaining-medical-license

99 VD March 7, 2017 at 11:46 am

The state licensing boards primarily exist to discipline bad doctors. This would be easier done at the state level than the federal level. National databases of physicians already exist (dea and medicare databases of providers).

100 Slugger March 7, 2017 at 11:50 am

It would be helpful to know the number of terrorist caused deaths from these nations in order to be able to makeb a cost/benefit analysis.

101 Troll me March 7, 2017 at 1:02 pm
102 Thomas March 7, 2017 at 2:13 pm

None of thoae nations provide any support for terrorism. None of those nations contain individuala that would kill Americans if given the opportunity. These are the falsehoods implied by Nathan’s dumb analysis of risk.

“How many times has someone banging on your door at 2am hurt you? Just open up” – Nathan, thinking

103 Troll me March 7, 2017 at 2:46 pm

I thought the subject was terrorism in the US.

Do Americans only care about terrorism against Muslims when it provides an excuse to complain about dangers which are not materialized in the USA but which are very present in imagination?

104 Thomas March 7, 2017 at 5:43 pm

What you refuse to acknowledge, because you are a racist who prefers brown people, is that many of the muslims of the Middle East would, if given the opportunity, kill Americans. All evidence suggests that this group of people is disproportionately more likely to engage in random acts of violence against Americans than any other group of people in the entire world, your racial prejudices notwithstanding.

105 Troll me March 8, 2017 at 11:56 pm

Thomas, do you realize what a piece of shit you have to be to think that it`s an INSULT to suggest that I have no problems with brown people?

Thank god there are too many like you. Just very outspoken. Maybe a little (lot) brainwashed too.

106 Slocum March 7, 2017 at 12:00 pm

Unfortunately, immigrant MDs don’t increase the overall supply because of the requirement that they repeat residency here (competing with native trained MDs for a fixed number of limited residency slots). As a result, many immigrant MDs end up working as nurses or PAs because of the roadblocks thrown in their way. What need to happen is that we need to get rid of the barriers to entry for both the country and the profession. But I’m not holding my breath.

107 albatross March 7, 2017 at 1:47 pm

About 25% of doctors in the US are immigrants. I suspect that reflects a fairly sensible part of our immigration policy–importing people with useful skills and high IQs who will contribute a lot to the country, and whose kids will probably not be a burden.

I guess these five countries are then providing about 1/25 of all immigrant doctors. That doesn’t seem all that out-of-line with their populations and such, especially given the strong incentives people from those countries have had to flee to the US.

108 Rick Zhang March 7, 2017 at 2:32 pm

Though from a brain drain perspective we are contributing to Syria becoming a failed state with no indigenous medical work force of its own.

109 Cooper March 7, 2017 at 1:51 pm

Since 1952, the number of medical residencies available in the US has increased from 10,000 to 24,000.

The number of US medical school graduates has increased from 7,000 to 38,000.

https://physiciansnews.com/2013/02/14/this-chart-is-scaring-medical-students/

Our physician shortage is about the lack of federally funded medical residencies. Nothing else comes close to mattering by comparison.

110 John Mansfield March 7, 2017 at 2:09 pm

Any ideas why residencies are the bottleneck? It seems that there would be plenty of hospitals and clinics glad to employ more of those low-paid, hard-worked resident slaves. Or do physicians just exaggerate about the hardship of their residencies?

111 Rick Zhang March 7, 2017 at 2:35 pm

Many hospitals would love to have more spots, but the approval process is long, and not every community hospital has the qualified personnel to become the program director of an accredited program. Furthermore, Medicare residency dollars are limited, and that constrains the number of new sites that can open. Now one wonders why private money (e.g. charitable foundations) hasn’t been used to fund more spots…

These low-paid hard working slaves actually need another physician to supervise them, so in some cases it can be a net drain for the hospital. See my above post for a proposed solution, which involve allowing residents to bill Medicare. Granted that would explode the Medicare budget in a different way, but in the end, someone always pays somewhere.

112 Bob from Ohio March 7, 2017 at 2:07 pm

You have to root around a bit but eventually there is a linked New York Times article that say:

“Across the United States, more than 15,000 doctors are from the seven Muslim-majority countries covered by the travel ban, according to The Medicus Firm, a firm that recruits doctors for hard-to-fill jobs. That includes almost 9,000 from Iran, almost 3,500 from Syria and more than 1,500 from Iraq.”

3/5 are from Iran. How many have been here for decades?

In fact, how many of the doctors from the other paused countries have been here for decades?

Of course they are all unverified figures provided by a “firm that recruits doctors” which has a vested pecuniary interest in keeping a supply coming.

Lies, damn lies and statistics

113 Bob from Ohio March 7, 2017 at 2:12 pm

“I found that a surprisingly high number.”

There is of course no easy way to verify these figures. You are supposed to just accept them.

114 AlanK March 7, 2017 at 3:43 pm

I opened the data and they are too aggregated to assess. What is the distribution of the doctors among the 6 countries? I suspect Somalia, Sudan, and Yemen do not generate too many physicians these days. Libya I assume at one time had a functioning medical education infrastructure as does Iran. The other question is when did most of the Iranian doctors arrive. Are these mostly the ones who fled after the Shah or are they more recent immigrants. My own non-scientific observation is that the vast majority of non European US immigrant physicians are Indian, Chinese, Filipino, Egyptian, Lebanese, Nigerian, and Latin American.

115 M March 7, 2017 at 4:10 pm

Not totally so surprising to me.

Firstly, medicine, as a profession, tends to be a) quite family structured (e.g. lots of doctors tend to have a parent or family member who was – we’re not very good at opening it up to any talented person), and b) perceived to be particularly demanding on norms of hard work and ambition that are common in first and second gen migrants (whether or not its actually that much hard work!).

At the same time, c) capacity to produce medics does not really tend to vary a lot by country, at the technologically non-intensive General Practitioner level (e.g. fairly basket case countries still have good amounts of GP level doctors, because the tech and likely the IQ level needed for it isn’t so high), and d) medics are much more financially rewarded in the United States than elsewhere.

Western countries tend to tap out on home grown capacity for new medics faster than they do money for medics, after all folk from “medical families” and people who feel they have a mission in life are exhausted.

116 widmerpool March 7, 2017 at 5:32 pm

I don’t see how this is any kind of argument against the travel ban. Once the improved vetting procedures are in place, qualified doctors that meet character requirements should still be able to immigrate.

117 Raybury March 7, 2017 at 6:50 pm

When I heard this stat, it called to mind the recent Nobel Prize results where, before Bob Dylan was recognized, it was heavily touted that 6 of 6 American winners were immigrants. Immigrants! IMMIGRANTS!!!

Specifically, they were British and Scandinavian PhD holders, who earned those doctorates before immigrating.

Does anyone actually think that any significant share of those who favor restricting immigration would reject highly-educated people who are likely to be job creators? We’re glad to take your best, world; its the huddle masses yearning to institute mandatory Sharia that we would rather you hold onto.

118 cliff arroyo March 8, 2017 at 1:47 am

It’s a good thing that people in those countries don’t need medical care. In the very unlikely case they did, I guess they could all come to the US too!

119 blah March 8, 2017 at 4:12 am

“that more Americans die each year falling in the bathtub than from terrorism. The fact that Americans are 1,333 times more likely to be shot dead by a criminal than killed by a terrorist has not persuaded Congress to take the former nearly as seriously as the latter.”

Taleb drives this sort of bullshit to cleaners pretty well:

https://www.facebook.com/nntaleb/posts/10151641931853375

120 blah March 8, 2017 at 9:14 am

Oops I meant to post this in some other thread; in fact Tyler’s post, and got mixed up.

121 Horhe March 8, 2017 at 5:37 pm

If you count veterinarians as well, I’m pretty sure that these docs are responsible for 100% of the female genital mutilations that take place in Britain, as opposed to home countries during visits or before the immigration process.

http://www.telegraph.co.uk/news/uknews/crime/9219217/100000-British-women-mutilated.html

122 Andrew Kahr March 8, 2017 at 8:35 pm

The US either does or does not have an overall shortage of physicians. If it does, then (a) Train more, (b) STOP providing medical training to foreigners who are unlikely to live their lives in the US. I don’t believe there is such a shortage.

If there are enough MD’s in total, but in some way they are maldistributed geographically, by specialty or whatever, then provide tax and loan incentives and disincentives to fix this.

If we have enough MD’s in the right places, then stop allowing any foreigners to qualify to practice in the US. They can immigrate if they qualify, but they won’t be allowed to practice here. Fix that at the Federal level.

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