D R A F T

A Proposal for an Onondaga County

International Medical Graduate Training

ProgramPrepared by Matt Cortese, MD/MPH Candidate

SUNY Upstate Medical UniversityOffice of Diversity & Inclusion

For the Healthcare Initiatives for Community Inclusion Committee (HCIC)

3 June 2014

D R A F T

“Water, water everywhere, and not a drop to drink”

- Adapted from The Rime of the Ancient Marinerby Samuel Taylor Coleridge, 1798

“Doctors, Doctors Everywhere, and not a single job”

D R A F T

Presentation Outline

•Building the Case: The Problems We Face

• Health disparities

• Socioeconomic inequalities

• Healthcare professional shortages

• Shortage of physicians in Syracuse

• Shortage of minority physicians

•The Solution: An IMG Training Program

• The UCLA Model

• Program Components

D R A F T

Building the Case: The Problems We Face

• Problem #1: disparities in health and socioeconomic status in underserved communities in the City of Syracuse• There are numerous health disparities, including in mortality rates and

preventable hospitalizations

• There are also gaps in educational attainment, income, medical insurance rate,

• Problem #2: underutilization and unemployment amongst the local new American population in Syracuse• This includes 90+ healthcare professionals and International Medical

Graduates (IMGs)*

• Problem #3: shortage of primary care physicians in impoverished communities in Syracuse (MUAs and HPSAs**), especially physicians from underrepresented minority demographic groups.

*IMGs = International Medical Graduates, who are physicians trained in their native country**MUA = Medically Underserved Area ; HPSA = Healthcare Professional Shortage Area

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Problem #1: Health Disparities• There are significant epidemiologic health disparities in the City of Syracuse

• Age-adjusted mortality and premature death rates are about 2.5 times higher for non-whites than whites in Onondaga County

• Differences in socioeconomic status undoubtedly play a significant role in these disparities

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Problem #1: Health Disparities

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Problem #1: Socioeconomic Disparities

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Problem #2: Underutilization and Unemployment Amongst Highly-Skilled

Syracuse new Americans• The City of Syracuse is a listed resettlement and migration site, with about 800 refugees arriving on an annual basis

• As of last year, approximately 12,000 new Americans, including new and former refugees, currently reside in Syracuse, according to the Interfaith Works Center for New Americans.

• Included in this population are healthcare professionals, with ~90 qualified healthcare providers arriving since 2011 alone

• This also includes highly skilled physicians, including primary care practitioners and surgeons, most notably from Cuba

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Problem #3: Need for Health Services

• There is a critical shortage of primary care physicians in Syracuse, especially poor communities

• Onondaga County has 8 census tracts within it that are identified as Medically Underserved Areas (MUAs), with an average score of 55.73.

• 7 of these 8 MUAs are located in the City of Syracuse

• An MUA uses an Index of Medical Underservice (IMU), and ranges from 0 (completely underserved) to 100 (completed served), with a score less than 62 designated as an MUA

• Metropolitan areas are split into Census Tracts representing neighborhoods with similar demographic and socioeconomic characteristics

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Problem #3: Need for Health Services

City of Syracuse, Onondaga County,

New York State

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Problem #3: Healthcare Workforce Diversity

• Based on U.S. population American physicians and surgeons are :• Overrepresented in both

Asian and White racial demographic groups

• Underrepresented in Hispanic and Black demographic groups

• Only 8% of physicians in NYS are among an underrepresented minority demographic group• These physicians are

disproportionately located in urban HPSAs

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Problem #3: Healthcare Workforce Diversity

Source: Gray & Stoddard 1997, Journal of Community Health

• Minority patients tend to prefer minority physicians over non-minority physicians, especially those of Hispanic ethnicity• Personal preference

and language compatibility, not simply geographic convenience, are factors

• Racial and ethnic concordance between patients and physicians has been shown to increase in #’s of participatory visits, patient satisfaction, and receipt of preventive care.

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The Solution: An International Medical Graduate (IMG)

Training Program• The creation of a pre-residency IMG training

program to help IMGs in our local community become contributing members of our healthcare workforce in Syracuse MUAs/HPSAs

• In other words, create a “pipeline” for IMGs into the American healthcare workforce

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A Working Model: UCLA• The David Geffen School of Medicine at UCLA is currently developing an IMG pre-residency training program for the same problem

• This program is designed to develop a workforce of bi-lingual, bi-cultural IMG physicians to address similar shortages of healthcare professionals (HPSAs/MUAs), particularly minority practitioners

• High-intensity full-time program

• The ultimate goal of the program is to place qualified IMGs in Family Medicine residencies, particularly in HPSA/MUA areas

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Proposed Program Components

• Intensive English as a Second Language (ESL) Training

• Includes TOEFL (Test of English as a Foreign Language) exam prep

• Shadowing/observation opportunities in American healthcare settings

• Electronic Medical Record (EMR) Training

• USMLE exam preparation courses and materials for board certification

• Short-term – provide study materials and financial assistance for review courses

• Long-term – establish pipeline for local IMGs with local residency programs

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Why It Will Work for Syracuse

• Critical need for healthcare professionals in Syracuse (7 HPSAs)

• IMGs have been shown to be more likely to work in metropolitan MUAs as compared with American-trained physicians

•Minority physicians are underrepresented, comprising only 8% of all physicians in NYS, while minorities comprise 29% of the NYS population

• Increasing the number of minority physicians will help to improve healthcare quality and access for minorities in Syracuse, which comprise nearly 30% of the City’s population and many of whom live in an HPSAs/MUAs

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Why It Will Work for Syracuse (continued)

• Syracuse is an established resettlement site for refugees, including 90+ healthcare professionals arriving since 2011 alone

• Literacy organizations that provide ESL training already exist in Syracuse

• Syracuse has 4 hospitals and a medical school (SUNY Upstate) that already provides USMLE preparation courses and pre-residency training

• Expanding primary care access and preventive services have been shown to reduce long-term healthcare costs – an important concern in the current political and socioeconomic climate

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Potential Obstacles and Solutions• English proficiency can take years to master, particularly at the high

level demanded of medical professionals

• Expanding funding to literacy-promotion groups may help address this problem

• Collaboration with local literacy groups may help with this

• Barring policy changes that allow for adequate, steady funding or reimbursement to participating institutions, the cost of USMLE and ESL preparation classes may not be recouped at the program level

• Grants or reimbursement/tax-credit legislation for IMG training programs would help alleviate costs.

• Graduate Medical Education (GME) residency slots have not expanded proportionally with population growth or medical school graduation rates

• This means that residency slots for IMGs will become increasingly competitive

• Can be addressed by additional funding of GME residency positions, especially in much-needed primary care fields

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Implementation Steps

•Reach out to local residency programs (GME offices)

• Focus groups with new American IMGs

•Reach out to community to be served to assess local healthcare needs

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By providing meaningful career development tools to highly skilled new

Americans, this program will:•Help reduce underemployment for highly-skilled new Americans while building the healthcare workforce in HPSAs/MUAs

•Help combat health disparities by providing care in the poorest communities in Syracuse

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References:

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• 2. Cooper-Patrick L, Gallo JJ, Gonzales JJ, et al. Race, gender, and partnership in the patient-physician relationship. JAMA. 1999;282(6):583-589.

• 3. Doescher MP, Saver BG, Franks P, Fiscella K. Racial and ethnic disparities in perceptions of physician style and trust. Arch Family Med. 2000.

• 4. Gray B, Stoddard JJ. Patient-physician pairing: Does racial and ethnic congruity influence selection of a regular physician? J Community Health. 1997;22(4):247-259.

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• 6. Komaromy M, Grumbach K, Drake M, et al. The role of black and hispanic physicians in providing health care for underserved populations. N Engl J Med. 1996;334(20):1305-1310.

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• 15. Zerehi R.    How is a shortage of primary care physicians affecting the quality and cost of medical care?  A comprehensive evidence review. . 2008.

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