Charting the Future: International Trainees in U.S. Medical Education and Immigration Reform

Podcast Transcript

Dr. James K. Stoller:

Hello, and welcome to MedEd Thread, a Cleveland Clinic Education Institute podcast that explores the latest innovations in medical education and amplifies the tremendous work of our educators across the enterprise.

Dr. Tony Tizzano:

Hello. Welcome to today's episode of MedEd Thread, an Education Institute podcast exploring the topic of international trainees. I'm your host, Dr. Tony Tizzano, Director of Student and Lerner Health here at Cleveland Clinic in Cleveland, Ohio. Today I am very pleased to have Janice Bianco, Director of Visa and Immigration Services within our Education Institute here to join us. Janice, welcome to the podcast.

Janice Bianco:

Thank you, Tony.

Dr. Tony Tizzano:

Well, to get started, if you could tell us a little bit about yourself, your educational background, what brought you to Cleveland, and your role here at the clinic.

Janice Bianco:

Well, my background is originally in political science and sociology with the intention of doing political work or going to law school, and I ran a campaign. We lost, so I needed a job, and I got a job at the Educational Commission for Foreign Medical Graduates 34 years ago, and I ran their J-1 exchange visitor program. After five years a job popped up out of our fax machine for my former administrator, Pat Chapek, who many people will remember. And it was addressed to one of my employees, but I made a copy for myself as well. And Pat came to town to do medical student recruiting for the residency programs, and I interviewed. They brought me out of here, and I took the job. And I've been here for 29 years.

Dr. Tony Tizzano:

And doing great work.

Janice Bianco:

Thank you.

Dr. Tony Tizzano:

And we're still happy to have you. Well, in today's segment we want to explore the growing importance of international trainees, emerging opportunities for groups of learners, and the growing need for change related to current US immigration laws. If you could help us frame this topic a bit so our listeners have a better understanding of where we're headed.

Janice Bianco:

Sure. It's not an easy task for physicians in other countries, or graduated physicians. They have to take a series of examinations, the same way that graduates of US medical schools do, and it's called the US Medical Licensing Exam, and there's three parts to it. They have to take the first two parts, step one, which is basic science, and step two, which is clinical science. And then there's something called a Clinical Pathway. So, it's where they have some clinical experience, preferably in the United States, whether it's clerkship as a medical student or if they come and observe.

And once they pass through that and also take an English examination which is geared towards medical terminology, they will get an ECFMG, which is Educational Commission for Foreign Medical Graduates certificate. And that's sort of their passport to apply for graduate medical education in the US. So, once they do that they go through the same process, they apply through ERAS, the Electronic Residency Application Service. They match with a residency, and they will need one of two visas.

Either the J-1 Exchange Visitor, which is sponsored by the ECFMG, they're the only agency authorized by the State Department to do that. Or an H-1B which would be sponsored by the individual institution where they will be training. Not all institutions offer H-1B sponsorship. Cleveland Clinic has, since I've been here, and I think for a few years before, has always used it because we like to keep the doctors that we train, and it's much easier to keep them if they've been on an H-1 than if they've been on a J.

Dr. Tony Tizzano:

So, there's plenty of hoops to jump through.

Janice Bianco:

Yes.

Dr. Tony Tizzano:

What kind of numbers are we talking about?

Janice Bianco:

Well, I can't give you numbers nationwide for the H-1 because I don't know that the immigration service tracks that. They may, they may not. I can tell you that it's roughly 4 percent of the 65,000 H-1s that are issued every year.

Dr. Tony Tizzano:

Okay. So, substantial number.

Janice Bianco:

Yes. For the J-1s, when I left ECFMG 21 years ago we were at about 13,500. And it dipped. It went up and down for several years and now they're back up to that level again. And there's a lot of different reasons. There's, you know, different issues in countries where people are moving as much, or conditions get better in one country, or worse in another, so it's kind of an ebb and flow according to what's going on in the world.

Dr. Tony Tizzano:

Okay. Might you hazard a guess as to what percentage of trainees we have at the clinic in a given year?

Janice Bianco:

About 25 percent of our trainees are from international medical schools or other countries.

Dr. Tony Tizzano:

And in consideration of what they have to do to get here, these are absolutely outstanding individuals.

Janice Bianco:

For the most part.

Dr. Tony Tizzano:

Yeah.

Janice Bianco:

Well, they have to be, first of all, to get into Cleveland Clinic.

Dr. Tony Tizzano:

Right. Right.

Janice Bianco:

Some programs used to have score requirements, so they had to have a certain score on the USMLE exams. But I think they've pretty much done away with that because not everyone does well on standardized tests.

Dr. Tony Tizzano:

Yeah. And I think that almost all medical education is looking at a more holistic approach. But when they finally get here, what are the areas they tend to pursue?

Janice Bianco:

For the most part, I would say internal medicine and pediatrics are the top two, and then it filters down. There's some interest in radiology and pathology. I'd say probably pathology first. And general surgery, any of the surgical disciplines, we have a handful. But it's very, very competitive, and it's hard to get in if you're an international, particularly general surgery, urology. I've only seen us take maybe one or two in my whole career here in urology as a resident.

Dr. Tony Tizzano:

Okay.

Janice Bianco:

And the same goes with integrated plastic surgery and integrated vascular surgery programs.

Dr. Tony Tizzano:

What about cardiology? I would think it's like coming to mecca.

Janice Bianco:

Yes. Well, yes, it is. We have a number of our internal medicine residents who are from other countries go on to our cardiology program and do extremely well.

Dr. Tony Tizzano:

Yeah. Janice, you know, it's not lost on me, with all the effort you put forward and the degree to which we've been successful that we really are helping to enhance the diversity of our organization, which is a more and more important and more recognized perspective. And thanks for all that hard work. What about medical students and clerkships?

Janice Bianco:

I don't have numbers on that, but I do know we take at least two students per year from Abu Dhabi in connection with CCAD. And we have two that just started this week as a matter of fact. And I don't have to do anything with them regarding visa because they can use the visitor visa, which anyone can apply for at a US Consulate.

Dr. Tony Tizzano:

Okay. Understood.

Janice Bianco:

But I do advise them in terms of the next steps for getting into residency, and what they want to consider regarding the different types of visas.

Dr. Tony Tizzano:

Okay. And in terms of research, do some come just to pursue research?

Janice Bianco:

Yes. And at the Lerner Research Institute we have about 200 postdoctoral research fellows who are primarily PhDs. There may be a couple of MD-PhDs in there. We do have probably about 50 to 100 in the clinical departments doing clinical research programs. They don't have patient contact unless it involves clinical trial they're working on, so interviewing patients, collecting data, that sort of thing. And that's very popular with newly graduated physicians because they want that experience.

The more you have on your CV when you're applying to an academic medical center that also is a huge research institution like Cleveland Clinic, if you've got at least six months of research on there, it's a big plus because they know that you are going to active in your research going forward, as a resident, as a fellow, and that's what they look for. These are people who've graduated from medical school, but they come to just to do research. There's 16 categories of the J-1 exchange visitor visa.

Dr. Tony Tizzano:

Of course, there are.

Janice Bianco:

We are authorized by the State Department to (laughs) use the research scholar and short-term scholar categories. So, we bring in J-1 research scholars for Lerner and for clinical departments. And we sponsor roughly 300 of those per year.

Dr. Tony Tizzano:

Wow. That is fabulous. And so, might this actually be a gap for them between having finished medical school, looking to get a residency program that they really want, and trying to get some solid credentials in terms of research?

Janice Bianco:

Absolutely. And sometimes if they haven't completed everything, they need for their ECFMG certificate, they'll come here so that they can take the second exam while they're doing the research, or if they want an H-1B they have to take the third USMLE exam. That isn't required for an ECFMG certificate, but it's required if you want an H-1B visa, which is a temporary work visa. And the requirements are set by the Immigration and Naturalization, excuse me, that's the old term. US Citizenship and Immigration Service.

Dr. Tony Tizzano:

There we go. We have to have a new title whenever possible.

Janice Bianco:

Yeah.

Dr. Tony Tizzano:

So, given their druthers, once they've completed all their training, what are their options? Are they limitless, or are there certain areas they tend to gravitate towards?

Janice Bianco:

Again, it depends on the type of visa they have during their training and how long they've been here. The J-1 carries a mandatory two-year home residence requirement. The J-1, it's the alien physician category only used by ECFMG for graduate medical education programs, and they're automatically subject to a requirement that says they have to go home for two years before they can either apply for an H-1 or apply for change of status to a permanent resident.

There are waivers of that requirement, so if they're here on a J-1 and they want to practice in the US and eventually stay, they need to find a position that is in a health profession shortage area or medically underserved area. And the individual States Department of Health, like the Ohio Department of Health, determines whether or not they're eligible, the job is eligible, and they are eligible for it. And then they recommend to the US State Department that they grant a waiver.

Dr. Tony Tizzano:

Okay. Understood.

Janice Bianco:

And then they have to the Immigration Service to change their status. It's like a four-step process. It takes forever sometimes. Yes.

Dr. Tony Tizzano:

There has to be a minimum of four steps to get anywhere. So, do some of them gravitate towards academic institutions if they can?

Janice Bianco:

If they can, if the institution is in a health profession shortage area as determined by the Center for Medicaid and Medicare Services. Yes. Or if they are in a medically underserved area. It's easier if you're in primary care because that's the highest need in most areas, but not all academic medical centers are in HPSAs, which is the Health Profession Shortage Area.

Dr. Tony Tizzano:

Okay.

Janice Bianco:

Our main campus, for example, is not for primary care. It is a mental health Profession Shortage Area, as are most of our Northeast Ohio facilities, which is kind of disturbing, but at the same time understandable. It's ho- not easy to get a waiver for main campus, but we have other hospitals that are primary care facilities that are recognized as a HPSA, the Southpointe Hospital is one of them. Lutheran Hospital, and several of the family health centers.

Dr. Tony Tizzano:

Oh, Wooster is not one of those by chance, is it?

Janice Bianco:

Actually, it is.

Dr. Tony Tizzano:

It is.

Janice Bianco:

Yes. Both the Wooster Family Health Center and the Milltown Center.

Dr. Tony Tizzano:

Okay. Excellent. Well, that's good to know. When we look at the backgrounds of these individuals as they look towards hoping to come to the US for their education, you know, what do they look like? What kind of scholars are they?

Janice Bianco:

We get some of the brightest people I've ever met in my life. Very often they're Fulbright scholars, they've won awards for being the top student in their medical school or their undergraduate school. They may have already published a research paper or gotten scholarships. They're just really exceptional and dedicated people. I've never seen a group of people work as hard as they do, and I think it's possibly because they need to prove themselves to get ahead here.

Dr. Tony Tizzano:

And in terms of their backgrounds, are these people privileged? Or can these be people who really are first generation students?

Janice Bianco:

It varies. I would say that most of them are from middle-class, upper-middle class, and upper-class families, if you want to use those distinctions. My favorite story is a surgery resident who was from, I believe, Peru, and he was the first person from his little village to go to college and to get medical degree. And he told me that, when he went back home, they would have a big celebration because he was like their hero.

Dr. Tony Tizzano:

Sure.

Janice Bianco:

And there was another physician who came for a fellowship for two years. He used his vacation. He would go back to Guatemala and take a portable EKG and go up into the mountains, to the rural villages, and hold clinics for the elderly people, or just anybody up there who needed health care.

There is the young woman, also, one of my favorite stories, only person in her family ever to go to college, from a small village in India. Came here by herself and did anesthesiology, and now she's a professor, I think, at Ohio State. And she was just so grateful that she had the opportunity, and its heart-wrenching, really. I mean, I'd moved away from my family, which as an Italian American is a big deal. If you don't live within 10 miles, it's a big deal.

Dr. Tony Tizzano:

I understand.

Janice Bianco:

Yeah. So, when I moved 400 miles away, you know, it was a really big deal. I can't imagine what it would be like to move thousands of miles away from your family and have very little opportunity of visiting on a regular basis. So, they make a lot of sacrifices.

Dr. Tony Tizzano:

Yeah. They're wonderful stories. What percentage do you think will go back? I mean, they've been here, they've seen all that we have, and all of a sudden, I can imagine them going back to an area where there, there aren't all these resources, but, but there's their family and there's their community, like you mentioned.

Janice Bianco:

Yeah. It's difficult because what I've heard a lot of people say is that they would love to go back and contribute and provide health services to their country. But there- don't have the resources. And case in point, we had a fellow who was actually stellar. He did some research on the mobile stroke unit, and he went back to India, and he was going to work there in a clinic, and s- you know, build up the program, but after a few years he left.

He went actually, I think, he went to Abu Dhabi. I don't know if he's at Cleveland Clinic Abu Dhabi or for- or one of the other facilities, because he couldn't get what he needed. And I had one of our interns tell me that they treat symptoms instead of diseases, so they can treat the symptom, but they don't have the resources to cure, or just alleviate, or even put into remission any kind of chronic conditions or, or serious conditions.

Dr. Tony Tizzano:

It sounds like early 20th century medicine. I mean, that's basically what we did.

Janice Bianco:

Yeah, unless you have, you know, the opportunity of working in a private clinic where, you know, rich people can afford to pay for their health care. But there are, you know, outlying places, just like here. There are rural areas where the nearest doctor might be 30, 40, 50 miles away. And it's not a good situation, and I hate to say that, you know, some of those countries, they say that we are draining them of their resources and their personnel.

But at the same time, they're not realizing that their lack of support for those people is really driving them to want to stay here. You spend three to seven years here as a trainee, and you see all of the resources and all of the things that are available to you to do your job, and then you go back and there's one MRI machine serving a city of 30,000 or 40,000 or 50,000 people or more, and it takes forever to get an appointment. You're gonna burn out really quick.

Dr. Tony Tizzano:

No, and we see it. I know I had a friend who was injured in Costa Rica. Two MRI machines in the country. And in the city that they were at, it was broken.

So, they had to remain in a hotel until they could be transported across the country to another. And certainly, in India, I've had the privilege of doing some speaking there and I visited a hospital in Mumbai. A city hospital, and I also got, it was unbelievable.

Janice Bianco:

Yeah.

Dr. Tony Tizzano:

And, you know, you think about all the disadvantages, at the same time everyone was in a neatly pressed white outfit, that had just apparently been ironed. But then I got to see a private hospital as well.

Janice Bianco:

And never wrinkles.

Dr. Tony Tizzano:

But I think they iron every day.

Janice Bianco:

Yeah.

Dr. Tony Tizzano:

But seriously. Well, that's really intriguing. So, as these individuals prepare their curriculum vitaes and try to gain entry, you know, what are the key features that they need to have? I think you've mentioned some of them already.

Janice Bianco:

Well, if they want to practice at an ava- academic medical center, research and publications are a must. Some teaching experience is very important, which is why some of our internal medicine residents who are internationals try for the chief resident year, and that gives them an edge in terms of going to academic medical centers. The unfortunate part is, as I mentioned, if they're on a J they may end up working at a regional hospital or a private hospital that has no academic affiliations because they need to get rid of that two-year requirement, and it- it's three years, it's a three-year commitment. And that's what a lot of them are afraid of is that after those three years they won't have access to research and teaching, and it will kind of, their skills might diminish, or it'll be a negative on their CV.

Dr. Tony Tizzano:

And I imagine they really need to get to know some of the mentors or people who head up their clerkships because they really, probably have to have very strong letters.

Janice Bianco:

Yes, they need very strong letters of recommendation when it comes to applying for residency and especially when it comes to applying for a fellowship. So, recommendation letters are important, a good, strong CV with decent grades in medical school, a good transcript, rather, and just experience. And actually, the personality. You can tell when you speak to some of these people that they actually love what they do, and they really care about their patients, and they really want to make a difference. And I just think, you know, I'm biased, of course.

Dr. Tony Tizzano:

No, but, but you get to know them better than most. So, what do you think in terms of our international trainees in our talent pipeline?

Janice Bianco:

Oh, here at the clinic we have an incredible pipeline, and in fact several institute chairs. Dr. Raed Dweik is an international medical school graduate. I did his J-1 visa, application through for ECFMG. He obtained a waiver, and he's chair of the Respiratory Institute. Dr. Andre Machado came here as a fellow from Brazil. These men are so bright, it's just unbelievable.

And Dr. Margaret McKenzie, when she came here, actually, she- she was already a citizen or a permanent resident. But she started out as a student on an F-1 visa, at Wash U in St. Louis, and to me she is like the poster child for international education, because she started out as a- a s- medical student at Wash U and now she is president of two hospitals, Marymount and Southpointe. And she's done an amazing job at Southpointe. It's just testament to how good it is to get these people in.

Dr. Tony Tizzano:

I know Margaret. You can't say enough about her.

Janice Bianco:

Oh.

Dr. Tony Tizzano:

She is fabulous.

Janice Bianco:

She's one of my physicians, and I love her.

Dr. Tony Tizzano:

Well, in family, she's taken care of my family, and she is absolutely outstanding. So, when you look at these individuals graduating and then, or even while they're training, I'm assuming their salaries and benefits are the same.

Janice Bianco:

Oh, yes. That's the law. Actually, on a visa, on the H-1 visa, we have to prove to the government that we are paying them at the same wage level as anyone else, regardless of their status, and that we're not displacing a US worker.

Dr. Tony Tizzano:

Okay. Well, that's interesting. I wonder if the opposite would be true, if we were there.

Janice Bianco:

In other countries?

Dr. Tony Tizzano:

Yes.

Janice Bianco:

I don't know. Maybe not.

Dr. Tony Tizzano:

So, I didn't mean to get off on a tangent there. So, are there organizations that once they're here provide some level of oversight?

Janice Bianco:

Well, yes. There's the Accreditation Council for Graduate Medical Education that oversees all graduate medical education residencies and fellowships, and also accredits them. They set the requirements for graduation from those programs. There's also the American Board of Medical Specialties which is the group that oversees the b- specialty boards that certify physicians in their field. And, of course, when it comes to visas, there's the State Department that oversees the J-1s and there is the Immigration Service which oversees the H-1 process.

Dr. Tony Tizzano:

So, again, a lot of bureaucracy is behind that, which brings us to, you know, Dr. Stoller always likes to say, "If you had a magic wand, so if you were given a magic wand, what would you do with current immigration laws?" And, because you've had an enormous depth and breadth of experience in this area.

Janice Bianco:

We're working basically, the immigration laws have been passed, the most comprehensive bills passed in 1965. There've been a few amendments along the way in the '80s and the '90s, but we're basically working with rules that were built around how the world existed and operated in 1965. It's very arbitrary. There are certain rules that apply to some people but not to others. One of the examples is on the H-1B you're required to have USMLE step one, two and three, if you're a physician, and a license for where the position you will hold. Now, graduates of Canadian medical schools are different because their schools are accredited by the same organization as our schools.

So, their exams and their schooling and their training are all accepted here in the United States as equivalent. And the State Medical Boards will accept their Canadian medical examinations and give them a permanent license. The Immigration Service will not do that. So, you have a Canadian physician, went to McGill, let's say, did their residency, they want to come down here do fellowship or work or something, and if they want to stay here permanently, they have to take a second set of examinations that they don't even need in terms of practicing their profession. It's just so they can get a visa.

Dr. Tony Tizzano:

So, some overhauling needs done.

Janice Bianco:

A lot. We need a one-stop visa that goes from medical school through practice. And if you want to put two-year requirements in there and everything, I that's fine. The State Department from time to time complains about the number of waivers, and when people are applying for certain programs in J-1s they say, "Oh, is this person gonna end up getting a waiver?" And sometimes they have to sign a statement that, "No, they won't apply." But at the same time the same group handles the waiver applications. So, if you don't like it, either take the waiver option out, or remove the two-year requirement.

Dr. Tony Tizzano:

Yeah. But it seems clear as a bell. Well, I hope that's on the horizon. So, you mentioned before, and I just want to touch on this because I thought it was interesting, this Deferred Action for Childhood Admissions.

Janice Bianco:

Yes.

Dr. Tony Tizzano:

Tell us a little bit about that, because I thought that was very interesting.

Janice Bianco:

That is the most ridiculous thing. The Deferred Action for Childhood Arrivals, they're individuals who were brought here by their parents as infants or as children, very young children. They had no choice. Their parents were coming here to work so that their child could have a better life and a better chance at success. And we've had a few in our residency programs, they are outstanding, and they make their parents proud, one hundredfold. 34,000 of them, of the DACA recipients are in health care professions.

Dr. Tony Tizzano:

Amazing.

Janice Bianco:

Some of them are running clinics for underserved populations, for minorities. Some of them have started organizations to help other DACA recipients, and 20,000 of them are educators, so teachers in elementary and high school and colleges. It makes no sense to me, here's an example. I thought of this the other night. After the Second World War, our government turned a blind eye to not see scientists, to bring them here to further our efforts in the nuclear weapons race, but they will not approve a child who has succeeded beyond belief and can contribute so much to humanity and health in the United States and grant them permanent residence or citizenship. Now, how backwards is that?

Dr. Tony Tizzano:

This is where you need the magic wand.

Janice Bianco:

Yes.

Dr. Tony Tizzano:

Yeah. For sure. You know, as you say all of this, it's not lost on me that international trainee, as they matriculate and come into the workforce, what would health care be like in the United States if we didn't have them?

Janice Bianco:

I imagine it would be a lot like it is in- in other countries where they socialized medicine, like the UK, which is kind of revising their plans now, and I think Canada is, too. But if you want a specialist in some countries you have to wait months and months. I have a friend whose in-laws live in Canada, they're Canadian. She needed an MRI and she had to wait six months to get an appointment with the specialist. She couldn't get an appointment to see a pulmonologist, and she was having lung issues. And that's Canada. I mean most people think of it as another state. So, and if it's bad in rural areas now, we're talking it would be kind of like going back to the turn of the 20th century.

Dr. Tony Tizzano:

That's the feeling I get. So, what have I missed? What are some things that you would like our listeners to know that I neglected to ask?

Janice Bianco:

Well, there’s one really good thing that's been happening, and that is that the ACGME, which accredits US schools, developed ACGME-I, which is the ACGME International, and they set it up so that there's an organization that's parallel to them that accredits residencies at foreign medical institutions. One of the biggest users of that is the American University of Beirut, which is one of the premier medical schools in the world. The other one is Aga Khan in Pakistan, which is also an outstanding university. And what this does is, it allows people who finished training to an accredited residency in their home country, if it's available.

For example, somebody who does internal medicine a- in AUB, is now eligible to enter an accredited fellowship in the United States without having to redo their residency. So, prior to this, if you did internal medicine in AUB when it wasn't accredited and you wanted to do a fellowship here, that is accredited and you get a certificate, you have to start from the beginning, all over again. And that is gone now for a lot of the graduates from these schools. This past year we hired four staff physicians who were able to bypass that extra time and start working here immediately after their fellowship.

Dr. Tony Tizzano:

Boy, that really resonates with me. In- during my training in residency and obstetrics and gynecology, we had a woman who came from India. She'd been practicing attending. She did an unofficial fellowship in GYN oncology in Cincinnati, with an extraordinary surgeon who took these individuals one at a time for two years. She decided, "I want to stay." She had a repeat residency.

Janice Bianco:

Yes.

Dr. Tony Tizzano:

As a first year was quickly recognized that she was exceptional, and nine times out of ten, if someone got in trouble in labor and delivery or in the operating room, attending or otherwise it was Karan, the first-year resident who got called to come in and help. She had seen so much in her training and had done so well. She was absolutely amazing. Well, Janice, I want to thank you so much. This has been an outstanding podcast. To our listeners, thank you for joining us and we look forward to seeing you on our next podcast. Have a wonderful day.

Janice Bianco:

Thank you, Tony.

Dr. James K. Stoller:

This concludes this episode of MedEd Thread, a Cleveland Clinic Education Institute podcast. Be sure to subscribe to hear new episodes via iTunes, Google Play, SoundCloud, Stitcher, Spotify or wherever you get your podcasts. Until next time, thanks for listening to MedEd Thread and please join us again soon.