Brain Gain: Foreign doctors are a vital part of the U.S. health care system, but at what cost?

Brain Gain: Foreign doctors are a vital part of the U.S. health care system, but at what cost?

With his phones, pager and list of patients, neurosurgeon resident Jaime Martinez heads to the Emergency Department at the Medical University of South Carolina to check on a patient Thursday, March 16, 2017, in Charleston. Grace Beahm/Staff

Perfection — every movement of the scalpel, every diagnosis has to be right. Jaime Martinez wants to be perfect. And why should that be surprising?

A brain surgeon strives for nothing less. Martinez learned that in medical school. Your hands could maim or kill with a slip of the forceps; your mistake could snuff out memories, another kind of death.

So if he became a neurosurgeon — no, an elite neurosurgeon, one who could defuse tiny aneurysms and pluck out tumors — he would need the best training possible. Training away from the Dominican Republic, his home.

Which is why he stands here now in Charleston, in front of the Medical University of South Carolina, clutching a coffee from Halo. He has the distracted look of someone coming down from an adrenaline rush. His mind is still alight from the operation he saw earlier that day.

He begins to talk about the past and the paths that led him to this moment, paths taken by so many other foreign doctors: Brain drain from their countries. Brain gain for ours.

A deadly shortage

The world is desperately short of health care workers; more than 4.3 million doctors and nurses are needed simply to meet basic needs, the World Health Organization says. And surgeons are particularly scarce.

The U.S. surgical gap

The United States also has a widening surgeon gap.

Largely because of this gap, an estimated 5 billion people across the globe lack access to safe and affordable surgery. The result is catastrophic: 17 million people die every year from conditions that could be treated with surgery.

Putting that in context, 17 million deaths is 5 million more than the combined deaths from malaria, tuberculosis, pneumonia, HIV/AIDS and diabetes.

Ethiopia has about 150 surgeons for its 92 million people. (South Carolina has more than 1,000 surgeons for its almost 5 million people.) Burundi has 13 surgeons for its 10 million people. In Sierra Leone, 1.5 million people need some form of immediate surgery, a recent study found. But the country had just 10 surgeons, and that was before the Ebola epidemic.

Despite this widespread skills deficit, the Gates Foundation, WHO and other big funders in global health circles have only begun to think hard about this issue. A charity executive once called the worldwide surgical deficit “the biggest global health problem no one has ever heard of.”

Residency is where the alchemy takes place, where freshly minted doctors become surgeons, and Martinez, 29, is in the thick of it: one sleepless night after another, week after week, 197 procedures last year, probably even more this year. And because it's neurosurgery, you find yourself telling one patient after another that there’s only so much a surgeon can do in their cases. There are limits, even if you’re perfect.

He sits for a moment in the courtyard, a welcome break after an unusually short shift. He wears a dark jacket over his blue scrubs. He has a thick dark beard. Round brown glasses frame warm brown eyes that dart back and forth as if he’s working on something, which he is: his patients, his next shift later that evening; text messages from his wife, studying now in the library to be a dermatologist; the operation he’d done earlier that day.

That one was special. A patient arrived after suffering for years with an uncontrollable cough. Medicine hadn’t helped. Tests showed nothing amiss in the lungs or upper respiratory tract. No one could figure out the cause. Except for his mentor here, Sunil Patel. Patel discovered an artery was pressing on a nerve and the brainstem. To fix the problem, Patel opened the patient’s skull, peeled apart the brain and inserted a tiny piece of Teflon between the artery and nerve. As far as Martinez knew, no other doctor in the world does this type of operation.

"Awesome," Martinez says, thumbing through photos on his phone that he saved from the microscope's camera.

This is one of the reasons why he’s here — to learn the world’s most advanced neurosurgical procedures, expand his own idea of what he is capable of, do things he could never do in the Dominican Republic.

Brain drain has occasionally triggered criticism. As far back as 1967, Walter Mondale, then an American senator from Minnesota, said it was “inexcusable” that the United States should “need doctors from countries where thousands die daily of disease to relieve our shortage of medical manpower.” A Congressional report in 1974 said brain drain would widen the rifts between wealthy and low-income countries.

But hospitals in wealthy countries needed health care workers, and foreign physicians and medical students answered their calls. Between 1993 and 2002, 604 out of 871 new doctors in Ghana left for the United States and other countries. Top "sending" countries to the United States include India, Philippines, Mexico, Pakistan and Dominican Republic. A study in 2015 found that 11,787 doctors in the United States came from sub-Saharan African countries such as Liberia, Ghana and Nigeria. That’s more doctors than you'd find in 34 African countries combined. Vikram Patel, an Indian psychiatrist, calls this "the Great Brain Robbery."

The result: One in four physicians in the United States received their medical degrees overseas. (In South Carolina, the ratio is lower — one in 10.)

"No American policy body — certainly not the U.S. Congress — has ever advocated that we 'offshore' one-quarter of our medical training or design a system in which our medical schools are only capable of training three-quarters of the physicians we need," Fitzhugh Mullan, a George Washington University health policy expert, told Congress in 2009. "Yet that is what we have done."

The United States would have even more immigrant doctors if it relaxed visa and licensing requirements, as some American health care industry officials advocate. Now, foreign doctors interested in practicing in the United States must do a medical residency at an American hospital — even if they've already done one in their countries. In 2014, the United States issued work visas to more than 15,000 foreign health care workers. Nearly half were physicians and surgeons.

This flow of doctors to the United States brings undeniable benefits, particularly the nation's poor. Once in the United States, foreign doctors are twice as likely to practice in public hospitals and in areas of high poverty, experts say. A study in February found that patients of immigrant doctors are less likely to die than if treated by U.S. medical school graduates.

But brain drain also is a silent educational aid program from the poor to the rich. Many African governments subsidize the educations of their health care workers, so when new doctors and nurses leave the governments' investments exit with them. The United States saved $846 million in training costs because of immigration from just nine African countries, one study in 2011 found. The United Kingdom was an even bigger beneficiary, saving $2.6 billion.

The Trump administration's short-lived travel ban earlier this year offered a rare glimpse into the impact of foreign health care workers. Residents from the banned countries were turned away from airports or detained at airports. Hospital officials feared worsening manpower gaps. The ban affected more than 1,000 non-U.S. citizens who applied for residency slots.

"How does America manage not to have uninsured people dying in streets? Well, the way we do it is with immigrant doctors,” said Amy Hagopian, a global health professor at the University of Washington who has done extensive research into brain drain in Africa.

Foreign medical residents are a key part of this system.

"They are how we take care of poor people," Hagopian said. "They show up in emergency rooms and get assigned to (medical) residents."

Martinez is here, but that doesn't mean he doesn’t love his country.

He grew up in the city of Santo Domingo. His father is a dermatologist and his mother an accountant. It was his mother who expected perfection: a clean room, no cutting corners on homework. He attended a Jesuit school, which reinforced this strict discipline. It also required him to do social work, and he found himself in pediatric hospitals, wrapping gauze and talking to patients, children who walked on their hands because of deformities, children with cancer.

“Some were so cheerful,” he recalls. “I wanted to help.”

He attended medical school in the Dominican Republic, where he quickly distinguished himself. Especially in anatomy class. His stern, Cuban-trained teacher gave tests so difficult he added two two-point bonus questions. Martinez earned a better-than-perfect score of 104. His instructor was so impressed that he made Martinez a teaching assistant — even though Martinez was still a student.

“I think you’re good at what you’re passionate about, and I loved anatomy. I can remember all the structures, but sometimes I forget people’s names. And when I learned neuroanatomy, I knew that was it.”

The brain in all its complexity and majesty. He would become a neurosurgeon.

And, “when I was done with my training, I wanted to be perfect."

But the Dominican Republic’s health care system could be enormously frustrating. In some hospitals, especially the public ones, he'd walk into rooms filled with hospital beds, rooms overflowing with patients and families, hospitals with poor infection control procedures and short of supplies.

One time he noticed something wasn't right with a patient. Hydrocephalus? A vasospasm? He wasn't sure. She needed a CT scan. But the family couldn't afford one. So he paid for it himself.

“What could I do? Let the patient die?”

Another time he saw a patient die from a gastrointestinal bleeding issue. She died as two departments in the hospital fought over what to do.

“I tried to figure out the best way to help my country. If I wanted to be good at this, I had to go, no question about it.”

And his departure, he hoped, would be one way to honor his country. By leaving, he could become a brain surgeon who operates on delicate blood vessels and nerves, something just a few neurosurgeons in Latin America can do. He graduated first in his class and set his sights on the United States.

Bad forecast

America's physician shortage was caused, in part, by imperfect research.

In the 1980s and 1990s, the medical establishment warned about a coming doctor glut.

Trade groups said medical schools were turning out too many physicians. A steady stream of immigrant doctors also was flooding the ranks. A doctor surplus would be a waste of training dollars, health care officials said at the time. A doctor glut also could reduce wages — too much supply for the demand.

Congress responded in 1997 with a financial tourniquet, cutting Medicare subsidies to hospitals that taught medical residents.

This effectively capped the number of new residents that teaching hospitals trained each year. And this cap has all but remained in place for 20 years, despite a growing population.

But predictions of a surplus turned out to be wrong.

Forecasters failed to take into account major socio-economic shifts. North America's population not only was growing, it was aging, creating more demand for medical care.

At the same time, other forces were reducing supply: Doctors were retiring sooner, some fed up with long hours and increasing paperwork.

Millennials also were less likely to put in the kinds of workaholic hours old-school surgeons had often done; more doctors had working spouses, making longer days less tenable for those who wanted to spend time with their children.

And in 2003, new work rules limited medical residents' workweeks. In the past, it wasn't unusual for residents to pull multi-day shifts and wrack up 100-hour workweeks. The new rules limited residents to 80-hour weeks, a major reduction in relatively cheap labor.

The result: The nation will have a deficit of between 25,000 and 60,000 physicians by 2025, in just eight years, adding even more pressure for hospitals to seek doctors from abroad.

The future

Martinez knows it takes years to train a neurosurgeon: After medical school, a neurosurgeon might spend seven years in residency and one or two years of fellowship training before becoming a fully-certified surgeon.

"You make a lot of sacrifices," he says as the sun goes behind MUSC's library, and the air and his coffee cools.

It takes time to build surgeons, and the same is true in solving the surgical deficit. It's a process that won't generate results for years.

The good news in the United States is that medical schools in the past decade have increased enrollment by 27 percent. The bad news is that Medicare hasn't touched its cap on residency slots.

Meanwhile, international efforts to stop brain drain have generally been anemic. In 2010, the World Health Organization adopted a code to reduce migration of doctors from poor to wealthy countries. But the code is voluntary. Critics have said a key tool is missing: a mechanism in which wealthy countries would compensate source countries.

When Martinez finishes his training, he'll probably stay in the United States.

Here, he can practice medicine to his full potential.

"The nurses here are awesome — very knowledgeable and diligent. They get people into the CT machine (for tests) like magic. Everyone knows what to do: the nurses, the technicians. If a patient needs an intubation, you can call a rapid response team, and they're there within two minutes. Amazing."

His beeper goes off six times in 30 minutes. His eyes dart again toward the building where his wife is studying dermatology. He has more cases to do later in the evening.

When fully trained, he says he will return occasionally to the Dominican Republic.

"I'm sure I can help improve their systems and training."

He's not sure exactly what he'll do. He just knows he wants to help, knows that health systems aren't perfect, at home and in the U.S., but that shouldn't stop him seeking perfection for himself and his patients, wherever they are.

Source: By Tony Bartelme tbartelme@postandcourier.com  Apr 22, 2017