Our nation’s physician shortage has resulted in a large medically underserved population. The problem will only get worse with federal healthcare reform as more physicians opt out of federally sponsored plans or choose to not accept new patients in these plans.

The Educational Commission for Foreign Medical Graduates (ECFMG) has established minimum standards for International Medical Graduates (IMGs) to be eligible to practice in the United Sates. These minimum standards include passing Parts I, II, and III of the U.S. Medical Licensing Examination (USMLE) and completing 3 years of a medical training program accredited by the Accreditation Council for Graduate Medical Education (ACGME). The ECFMG works in concert with the ACGME and the American Board of Orthopaedic Surgery (ABOS), as well as with other agencies on a federal level, to ensure safety for patients and uniformity in credentialing. An IMG can, however, circumvent the minimum standards set by the ECFMG and receive an unrestricted license to practice in the United States without the credentials deemed necessary by the ECFMG, through the “teaching license” designation. The teaching license is a restricted license that allows IMGs with special expertise or knowledge to teach in an academic setting in the United States.

The number of IMGs on the faculty at the University of Arizona has increased over the past 4 years. Some of these faculty members, however, have not satisfied the ECFMG’s minimum standards to practice in the United States or are from countries where the medical education is not designated “comparable” to U.S. medical education standards by the National Committee on Foreign Medical Education and Accreditation.

The Arizona legislature allows IMGs with a restricted license to circumvent the minimum standards set by the ECFMG for 4 years. The assumption is that the academic setting provides some sort of formal curriculum that negates the need for the individual to complete an ACGME-accredited program. 

To my knowledge, the University of Arizona does not have a formal curriculum in a competency-based education for any of the IMGs who have joined its faculty. Further, although the Arizona statute allows visiting physicians to educate in the academic setting where they are supervised, IMGs at the University of Arizona are also credentialed to see patients and bill Medicare and Medicaid for payments. The supervision of a physician in this designation—which is required by the law—is done without any specific oversight by the State Medical Board and requires only the assent of the physician’s immediate supervisor. This leaves tremendous latitude in what such physicians may do, based entirely on the say-so of a physician supervisor who may or may not be intimately involved in the day-to-day care provided by this physician.

The IMG who then receives an unrestricted license and maintains it for 4 years has 7 years to pass Parts I, II, and III of the USMLE. This means that an IMG outside of the ECFMG rules could practice in the United States for 11 years without any formal curriculum of competency-based education. Lastly, the physician who practices with an unrestricted license after this process never needs to be board certified or meet the requirements for Maintenance of Certification (MOC).

I’m calling attention to this issue because Arizona is not unique in its interpretation of the applicable law; many other states allow IMGs this opportunity to avoid the education and certification process that physicians trained in the United States must navigate. I would think the American Board of Medical Specialties (ABMS) and ACGME would also weigh in on this issue because it certainly has implications for the credibility of the accreditation and certification process that has evolved in this country during the past 50 years, with its emphasis on competency-based education, training, and MOC.

It seems to me that this option is a step backward in the development of an impartial progression, which does not rely on an individual “supervising physician” to define competency, but rather on a process with deliberate steps determined by unbiased, independently established bodies for certification and accreditation. In an academic institution where competency-based education is required by these accrediting bodies, it seems logical to adhere to the minimum standards set by the ECFMG. These standards must be the minimum for hospital credentials to establish parity with U.S. students and residents.

William A. Grana, MD, MPH, is editor-in-chief of Orthopaedic Knowledge Online. He is also professor emeritus at the University of Arizona.

Commentary: Play by the Rules
Shepard R. Hurwitz, MD

Dr. Grana is correct in pointing out that the Arizona rules are contrary to the oversight that the ECFMG has on international trainees. ECFMG requires passage of the USMLE steps I, II, and III so that international trainees may obtain an unrestricted state medical license. Current ABOS board certification rules exclude international trainees from taking the certifying exams unless they meet the following criteria:

1. They perform an orthopaedic residency in the United States at an accredited program.
2. They are allowed on the full-time faculty of an accredited residency and serve in one program for 5 years, after demonstrating they have received the equivalent certification in their country of training.

The Arizona rules also circumvent the ABOS requirements for those IMGs who have completed orthopaedic training in their home country and wish to qualify through the alternate pathway (ie, serve on the faculty of a residency program and perform accordingly for the minimum 5 years). Without a valid license for up to 11 years, the Arizona rules give IMGs an unfair advantage over ABOS diplomates, who need unrestricted state licensure to become certified and to maintain certification. And it is an unfair advantage over other states that require IMGs to have a medical license to work as faculty of a residency program.

The ABOS and the other member boards of the ABMS that provide an alternate pathway to U.S. residency training have the same requirements concerning licensure and full-time faculty commitment over time in an accredited residency. Serious issues concerning competence and commitment must be raised by the actions of the Arizona Medical Board in creating a pathway for unlicensed surgeons to possibly gain credibility by working on the faculty of the Arizona teaching programs.

The ABOS would not certify an unlicensed surgeon and will not recognize the ‘teaching license’ of Arizona. Still, the ability of unlicensed surgeons to work up to 11 years without securing a regular medical license is an unfair advantage over those orthopaedic surgeons who play by the current rules. In this day when patient safety and surgeon competence are issues with the public, how can the inclusion of unlicensed and unsupervised surgeons be permitted?

Shepard R. Hurwitz, MD, is executive director of the ABOS.