Friday, June 11, 2010

Fellowships and Visas

I saw this updated webpage this morning from Dartmouth Hitchcock Medical Center on how to apply to their EP fellowship program. It contains this statement at the end:
Why do foreign applicants get a "Special note?"

For those not familiar, J-1 visas require the applicant to return to their country of orgin for two years before being eligible to return to the US. There are exemptions to this requirement to return to their country that can be granted, including a "No Objection Statement" from their government or the "Conrad Program." The Conrad Program is a waiver issued for a foreign medical graduate who has an offer of full-time employment at a health care facility in a designated health care professional shortage area or at a health care facility which serves patients from such a designated area.

H1-b visas are a 6- to 10-year visa permitting employers to temporarily employ foreign workers in specialty occupations, like medicine.

Each year, scores of applicants apply for these cherished specialty and subspecialty fellowship spots. Subspecialty medicine is already an incredibly competitive venture owing to the pyramid structure already inherent to programs with limited fellowship training positions.

But there is another aspect to selecting fellows that few (if any) programs will openly admit: they don't want to train their competition.

It is well-known that following their training, many fellows tend to prefer to stay at or near their training hospital - often because it is simply easier (and less expensive) to stay locally to work if possible. Many hospital programs know this - especially ones in upper-crust communities with more than one competing hospital system. As such, there is a bias toward hiring foreign-trained fellows in fellowship programs because programs don't have to worry about oversaturating their market. This, then, skews competition for fellowship programs toward accepting foreign applicants in lieu of US-born applicants.

Others will argue that no such bias exists - that application processes are careful to cull only the best and brightest. After all, they are "equal opportunity employers" that promise " provide equal opportunity to all qualified persons without regard to citizenship, race, color, creed, religion, sex, age, sexual orientation, national origin, disability, handicap, veteran or other legally protected status." Still others will say, "get over it," it's an international market for health care providers now.

No one can deny that there are benefits to cultural exchange that occurs when non-US physicians enter programs and that there are benefits to other countries when these doctors do return. But could medical schools inadvertantly be turning their backs on US-born medical students who have paid nearly $300,000 for their medical education just so they can avoid local competition and discrimination claims? Might there be a better way to offer health care to underserved areas in the US and abroad besides hiring foreign physicians for fellowship?

With the increased pressure to shrink subspecialty medicine in favor of primary care with health care reform, perhaps it is time we re-visit the J-1 visa issue for our US medical schools and fellowship programs. Maybe we should require all of our new graduates to work for two years in underserved areas before settling in their chosen community.

Then again, better to keep it politically correct and not discuss these issues, right?


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