The clinic waiting room was bursting as Dr. Juan Zambrano calmly assured a worried mother that her infant son was doing well and then hurriedly scanned his next patient’s records.
For years, foreign doctors like Zambrano, who comes from Ecuador, have been welcomed as saviors in the American medical world.
They have willingly served poor and minority patients, taking the toughest and worst-paying jobs at big-city and rural hospitals.
In return, they have benefited from superior medical training, frequently subsidized by the U.S. government and usually more sophisticated than what they would have received at home.
Foreign doctors not only have filled gaps left by Americans, but have brought badly needed skills. Often Zambrano, 29, is the sole Spanish-speaking physician at the pediatric clinic at the Hospital of the University of Illinois at Chicago.
There, foreign-trained physicians make up 80 percent of the hospital’s pediatric residents–a low-profile field that many American-born residents have disdained for glitzier specialties such as radiology or neurosurgery. (In Illinois, about one-third of the state’s medical residents in 1993 were foreign-trained.)
But the welcome for foreign-trained doctors, who account for nearly one out of four physicians in the U.S., is fading as seismic changes ripple through the health-care system.
The main reason is the expectation that there will be a glut of 145,000 physicians in the U.S. in four years, with a declining demand for specialists. Government officials and politicians now are saying that one way to protect Americans’ jobs and medical schools is to shut the door to foreign-born doctors.
“If it happened tomorrow, there would be a crisis in big urban hospitals,” said Dr. Quentin Young, chairman of the Chicago-based Health and Medicine Policy Research Group. He is against barring foreign doctors until there is a nationwide system that will fill the holes left by the foreign physicians.
Indeed, in Chicago and other inner cities where foreign doctors are disproportionately represented, the proposals raise critical questions:
Though American doctors are considered better trained, will they fill the less-glamorous jobs now taken gladly by foreigners?
And will Americans work for the lower wages foreign doctors have traditionally accepted? If not, will hospitals that rely on foreign doctors be forced to cut back services for the poor or turn to less qualified personnel to assume the tasks of physicians?
The Washington-based Institute of Medicine in January urged the government to financially support hospitals dependent on the foreign residents. But it also suggested that hospitals hire physician assistants or advanced nurses to replace the foreign doctors in low-income communities that already see themselves short-changed when it comes to medical care.
As the debate heats up, there are signs that a shift from foreign doctors already is occurring.
Some see a dimming interest in foreign doctors for residency slots. Residency programs are reluctant to take international medical graduates because of a fear that the government will cut its funds for foreign doctors, said John Gienapp, director of the Chicago-based Accreditation Council For Graduate Medical Education.
Jan Reese, associate dean at Chicago Medical School in North Chicago, observed: “There is increasing difficulty for them (foreign doctors) to get residency positions.”
The U.S. Department of Health and Human Services last August urged federal agencies to show more caution in handing out special visas to foreign physicians serving in needy areas.
Under the program, foreign doctors are excused from returning home for at least two years after working here in communities needing physicians.
Officials say the number of foreign doctors receiving these visas mushroomed in recent years. But they also question whether the doctors are idealistic or merely taking advantage of the system.
“It is not so much they (the doctors) want to serve, but they want to stay here,” said Joyce Jones, an HHS official in Washington, who sits on the board that reviews the visa applications.
In response to the more hostile climate, some foreign physicians have launched a countercampaign.
Addressing their critics, they largely discount the predictions of a doctors’ surplus and they maintain that an anti-immigrant mood is feeding the drive to keep foreign doctors out.
“I am concerned that we are not headed in the right direction,” said Dr. Biswamary Ray, the Indian-born president of the Chicago Medical Society. “What will happen to the inner-city hospitals? They will have to trade (foreign-born) physicians for nurse practitioners and physicians’ assistants.”
Ray’s group has about 7,500 practicing members in Cook County, and more than 40 percent of them are foreign-born, he said.
Indeed, foreign physicians are concentrated in the nation’s big cities, drawn by the medical schools and hospitals’ needs for large staffs to care for the urban poor.
Hospital officials are not sure that American physicians, however pressed by a tighter job market, will take the less desirable jobs.
“Will it happen? Maybe. Has it happened before? Never,” said Dr. Jerry Niederman, director of UIC Hospital’s pediatric clinics.
At South Shore Hospital, where the medical staff is 70 percent foreign-trained, doctors continually seek better-paying positions in the suburbs, said hospital president John Harper.
At the heart of the doctor surplus, many experts say, is the expansion of managed care, which has reduced the need for specialists. One study last fall predicted that, with the growth of managed care, half the nation’s hospitals will close, leaving a vast surplus of physicians.
The solution, suggested the Pew Commission study, is to require foreign-trained doctors to return home when their U.S. training ends. Usually about three-fourths of these physicians permanently stay in the U.S.
“If we have record numbers of our students, and we still do not have enough minority and women (physicians), why should we pay for the education of foreign students?” asked Dr. Don Detmer, a professor of surgery at the University of Virginia Medical School.
“It is our schools versus their schools, and we think our schools are better,” said Daniel Winship, dean of Loyola University Chicago’s School of Medicine.
The government currently pays about $3.5 billion a year for U.S. hospitals to train resident physicians, both from the U.S. and overseas. After paying residents’ salaries and other costs, financially needy hospitals use this money for other expenses.
This has led many charity and public hospitals to rely heavily on residents rather than permanent staff to care for patients.
A Republican-backed effort in Congress last fall would have changed this system by paying hospitals less for foreign-born, foreign-trained residents. The measure, tacked onto the Medicare bill, died in the House, though sponsors hope to try again.
Although some Americans question foreign physicians’ qualifications, Dr. Housam Attal, a resident at Loyola University Medical Center in Maywood, counters that the U.S. gets the world’s brightest and best because of the intense competition to come here.
“In this country there is a tremendous appreciation for quality,” said the 32-year-old Syrian, who is completing a five-year program.
Dr. Libbyette Wright, a dermatology resident at UIC, says it seems “realistic” to limit the number of foreign-trained physicians. But she also feels awkward with the message that America can no longer be the land of opportunity for strangers.
To be sure, America has opened a new world for Dr. Juan Zambrano, who arrived here two years ago. In Ecuador, where he graduated second in his medical class, he could not have specialized in pediatric immunology, as he has in Chicago.
Unlike most foreign medical residents, he plans to return to his native country. But his determination to go home does not make hearing the talk of excluding foreign-trained physicians any more palatable.
“Sometimes when we (foreign residents) get together, we say, `God, don’t they know how hard we work?’ ” said Zambrano, a soft-spoken, meticulous man highly praised by his superiors.
The assignment chart on the clinic wall on a recent weekday showed that Zambrano was not the only foreign physician on duty. The other residents were from the Philippines, India, Poland and Guatemala.
There was only one American among them.
