Kristina Sokolovska Konieczny studied medicine for six years so she could become a primary care doctor, then spent three years practicing family medicine. She worked in various places — at a public hospital, in the homes of people in underserved areas, in private practice, and at a top youth sports program doing sports medicine. “I always had an interest and desire to work with patients and help people,” she says.
But today she no longer practices as a doctor. Instead, she works as a nurse at a short-term rehabilitation facility in Boston.
The reason? Konieczny is an immigrant.
“I had my hopes up. I spent $5,000 for applications, then about $10,000 for the board exams, books, and prep materials,” she told me over the phone. “People can’t believe [it]; they can’t understand why doctors who come here with experience can’t get into the system.”
Konieczny, who attended medical school and practiced in her home country of Macedonia, came to the US seven years ago to join her American husband, whom she met years earlier while she was on a medical school trip to Boston. “I knew the time and expense” of getting certified to practice in the United States, she told me. “But I wanted to try anyway. It didn’t work out for me, unfortunately.”
The process of certification for a foreign-trained doctor is the same process an American who just finished medical school must go through — take the boards and enter into a three- to seven-year residency program. This may sound reasonable on the surface, but someone who’s already completed years of medical training in another country will likely have little appetite for going through it again. US residency positions are also highly competitive and limited in number. In 2016, there were 35,000 applications for 27,000 positions, and those positions often favor graduates just out of US medical school. In 2018, 56 percent of foreign doctors who applied were “matched” with a residency program compared to 94 percent of US medical students.
Keeping qualified doctors like Konieczny from practicing medicine in the US is a colossal waste of human capital, especially when looked at in the context of America’s looming doctor shortage. The Association of American Medical Colleges estimates that by 2030, America will be short 120,000 doctors. Not surprisingly, the shortage is even worse in rural areas, where there are fewer hospitals, fewer medical schools, and older, poorer, and sicker populations more reliant on programs like Medicaid that pay doctors at lower rates.
Of the doctors America does have, only 33 percent are general practitioners, compared with 50 percent in 1961. It has been estimated that our high supply of specialists, which include doctors like cardiologists, orthopedic surgeons, and dermatologists, leads America to pay an estimated $100 billion more per year in doctor salaries than other countries. But we need more general practitioners. Studies show a stronger primary care system is associated with better population health and slower health care spending growth.
And that’s not even looking to the future. As the national health care debate continues and the calls for Medicare-for-all increase, America’s doctor shortage is one issue that’s not being talked about enough. Medicare-for-all pledges to offer affordable coverage to all Americans. That would mean an influx into the health care system of 30.4 million Americans who are now uninsured, plus the millions of Americans who have insurance but cannot afford to use it. It is long overdue for the richest country in the world to provide basic health care to its citizens. But addressing this shortage of doctors, especially primary care physicians, is essential on the road to a more just health care system.
Addressing the doctor shortage on the road to universal health care
The US can and should make it easier for immigrant doctors to practice. Foreign-trained doctors are more likely to practice primary care medicine and more open to working in more rural and poorer areas. Konieczny, for example, applied to more than 200 residency positions in family medicine and internal medicine, quadruple the applicant average of 50 to 60 applications to those same specialties, many in rural areas. “From what I know, Americans are more picky about where they apply and where they practice. Knowing this, we foreign graduates apply to more areas,” she says. Foreign-trained doctors are also multilingual and multicultural. Konieczny speaks Macedonian, Bosnian, and Croatian, in addition to English and some Spanish.
We already know how we would implement this. There need to be more medical residency spots — at least 15,000 more, as proposed by the recent Resident Resident Physician Shortage Reduction Act of 2019, now in Congress. The schooling process for immigrant doctors should be easier, and medical training and experience from select foreign countries should count toward certification in the US. In addition to more residency spots, the health care system must allow more nurse practitioners and physician assistants to practice independently.
For a model of how this would work, we can look, as we often do, to our northern neighbor. In Canada, the government only requires an estimated half of its foreign-trained doctors to get fully retrained. The other half can be rapidly certified to practice medicine by proving that they received their medical training from a list of vetted medical schools in countries such as Algeria, Nepal, Argentina, and Macedonia.
The US already knows it has a looming doctor shortage, but it has become more urgent in the context of increased coverage, whether that’s through universal coverage and Medicare-for-all or some other form. If we as a country make the moral shift to health care as a human right, then we need enough doctors to make good on that promise. Adding more residency slots is an important first step, but residencies alone are not enough. The US medical community must also consider the primary care doctors who already live in the United States and who are ready and willing to practice medicine — if we let them.
After five years of trying, Konieczny let go of her dream to continue practicing as a doctor. That’s when she learned about the Boston Welcome Back Center, a resource for foreign-educated nurses. Prior to getting a medical degree, Konieczny completed a nursing degree, which she was finally able to transfer over to a US licensed practical nurse (LPN) certification. “Through this organization, I feel lucky,” she says. “I have met a lot of doctors who work jobs here in places like retail shops. I at least had nursing to fall back on.”
Konieczny continuing to advocate for allowing more foreign-born doctors to practice on US soil. She has spoken to the Massachusetts state legislature on this issue on behalf of the Massachusetts Immigrant and Refugee Advocacy Coalition and regularly shares her stories with her peers at the Boston Welcome Back Center. “It’s not right how the system is set up,” she says, and has vowed to keep fighting. She adds: “Foreign-trained doctors — don’t give up.”
Perrie Briskin is a dual degree MBA/MPH student at the University of California Berkeley Haas School of Business, where she studies universal health care.