How Foreign-trained Doctors are Filling the Health Care Gap in Greater Minnesota
To Milagros Zegarra, the forests and lakes of Bemidji are a far cry from the bustling streets and beaches of Lima, Peru.
Zegarra spent most of her years growing up in Peru’s capital city, attending medical school and beginning her career as a doctor there. But in 2002, Zegarra came to the United States, partly to escape the instability that was then affecting her home country, and partly to take advantage of an opportunity to work in a state-of-the-art medical facility, which she did as an internal medicine resident at the sprawling Texas Medical Center in Houston.
Today, she’s a nephrologist — a kidney specialist — at Sanford Bemidji Medical Center, working in a town of 14,000 people best known for its university and its statues of Paul Bunyan and Babe the Blue Ox.
Zegarra’s background may seem unique for a doctor in Greater Minnesota, but if the state’s health-care trends continue as they have been, it won’t be.
Minnesota is facing a doctor shortage. The Minnesota Department of Health projects that the state will have 2,000 fewer primary care physicians than it needs by 2025 — a dearth of doctors that is expected to hit rural Minnesota especially hard. Of the 133 areas the state has identified as having a shortage of primary care health professionals, all but two lie outside Minneapolis and St. Paul.
To fill that gap, health-care providers are increasingly looking to doctors like Zegarra. In fact, she is now among the more than 2,000 doctors trained in foreign countries who currently practice in Minnesota, a number that’s been steadily growing over the years: from 15 percent of the state’s practicing doctors 20 years ago to 22 percent this year, according to the Minnesota Department of Health’s Office of Rural Health and Primary Care.
In other words, the future of medicine in rural Minnesota isn’t just going to involve more people like Milagros Zegarra, it’s going to depend on them.
Shortage creates need, opportunities
There are several reasons for the doctor shortage in rural Minnesota, but the biggest one isn’t especially complicated. Greater Minnesota is aging. Senior citizens 65 and over now make up 19 percent of the population of non-urban areas of Minnesota, compared to 13 percent of the population in urban areas. Meanwhile, a higher proportion of baby boomers between the ages of 50 and 64 also live outside of the state’s urban areas, and their looming health issues that come with age also factor into the projected shortage.
At the same time, the need for doctors, especially in rural areas, has been exacerbated by the inability of the health-care system to keep up with demand. That’s largely because residency programs, the years-long training that all medical school graduates must complete to become full-fledged physicians, are largely funded by the federal government. In 1997, Congress capped the funding for residency programs at 1996 levels — and hasn’t raised it since. And though the number of residency slots has grown slightly over the last 20 years, they’ve mostly done so in high-demand specialties.
As Yende Anderson, who leads the state’s International Medical Graduate Assistance Program, says: “We’re at a perfect storm right now with all the factors converging.”
The need for physicians in rural Minnesota has increasingly been filled by the likes of Aby Philip. Philip grew up in Oman, attended medical school in India and went to residency in Hartford, Connecticut, where he also completed a medical fellowship in oncology.
He initially came to Minnesota out of necessity: He needed to fulfill a visa requirement to work in an underserved area. But then a funny thing happened. After his three-year requirement ended, he decided he liked Brainerd enough to stay there.
His life in Minnesota isn’t as dynamic as it was in Thiruvananthapuram, the city of 1 million in south India where he went to medical school — or even in Hartford, where he did his residency. But like many rural residents, Philip and his wife enjoy the slower pace of life, not to mention the city’s lack of traffic. “If you go to the DMV in Hartford, you have 50 people in front of you,” he said. “Here you have five.”
His decision to practice in a rural area has also given him a chance to climb the career ladder more quickly than he might have in an urban setting. Indeed, he’s now the chief physician at Essentia Health St. Joseph’s Cancer Center, where he’s worked for just over four years. Had he gone to a cancer center in the Twin Cities, he said, he would have had to compete with more oncologists with more seniority for such a position. “I obviously would not be the chief in three or four years,” Philip said. “I think that opportunity came to me sooner because it’s a smaller center here.”
For others, like Elsaid Rabie, there are other benefits of working in rural Minnesota. Rabie, who grew up in Egypt, wanted to be a doctor from an early age. “My dad had a terminal illness, and that shaped my future a little,” he said.
He began medical school in Egypt in the late 1990s and practiced in his home country through the next decade, but he had long wanted to leave to work in either the United States or the UK. “Overseas, there are a lot of limitations on how much you can do based on economic reasons,” Rabie said. “You can’t always practice medicine the way you should.”
By the 2010s, he had decided to come to the U.S. because he had a friend already moving here. He first landed in North Carolina, where he shadowed doctors and took the two U.S. Medical Licensing Examination tests required to get a residency in this country. Because he wasn’t yet tied down to any city or region in his new country, Rabie cast his net wide when he applied for residencies. He found a program in St. Cloud that he liked most, ranked it first and matched.
By the time he moved to Minnesota, Rabie was already familiar with life in the United States, though moving to central Minnesota wasn’t without its surprises. “It wasn’t a cultural shock; it was a weather shock,” he said.
Which doesn’t mean there weren’t differences he had to learn to navigate. “Overseas, when a patient has a terminal illness, you don’t tell the patient, you tell the family,” Rabie explained. “But here you’re obligated to tell the patient, No. 1. And you don’t tell anyone else unless the patient gives you the priority to do so. It takes some time, reading and learning how things are done, to get accustomed to the culture here in the states.”
Rabie said the biggest draw of working in rural Minnesota is the flexibility. Because he works in emergency rooms as a locum, or on a temporary basis, he gets to write his schedule a few months in advance. Though there are locum opportunities in the Twin Cities metro, Rabie said he has no interest. Instead, he works in central Minnesota cities like Wilmar and Montevideo and still lives in St. Cloud.
Both Rabie and Philip also say they have come to appreciate the relationships they have with their patients, many of whom come from vastly different places — and have very different backgrounds — from the two physicians.
Philip says that his patients often express gratitude simply for his presence in Brainerd, since it means they don’t have to drive to St. Cloud or the Twin Cities for cancer treatment. “Some of them ask me, ‘How did you end up here?’ he says. “But then they say, ‘We’re glad you’re here.’”
‘Slowly but surely’ making an impact
To ease the doctor shortage, the state of Minnesota would like to see more stories like those of Zegarra, Rabie and Philip. So in 2015, the Legislature approved the creation of a first-of-its-kind program to help international medical graduates find pathways to becoming practicing doctors here.
The International Medical Graduate (IMG) Program operates out of the state Office of Rural Health and Primary Care and helps international graduates find medical training and other support needed to qualify for residency.
To date, the state program has funded four residency positions at the University of Minnesota and Hennepin County Medical Center. IMG coordinator Yende Anderson said that number will increase to six by July. None of the doctors enrolled in the residency positions have graduated yet, but once they do, they will be required to work for five years in an underserved area in the state. “We’re having impacts, slowly but surely,” Anderson said.
Even with help from the IMG, those who train overseas face a daunting set of challenges to becoming a doctor here. For one thing, U.S. residency programs prefer to take people who graduated medical school within the past five years. Second, U.S. residency programs want to accept people with at least one year of clinical experience within the country. For students who attend American schools, that opportunity comes during the second half of their medical school career. But international graduates often have to locate places in the United States that are willing to allow them to do temporary clinical rotations.
International medical graduates must also pass two U.S. Medical-Licensing Exam tests, referred to as steps, and get certified by the Education Commission for Foreign Medical Graduates before they can qualify for residency. “It’s expensive and takes a good chunk of someone’s life,” Anderson said.
Even so, Anderson estimates that there are between 250 and 400 international medical graduates who want to practice medicine in the state but can’t currently do so under the law.
Consuelo Lopez de Padilla and Amro Abdelatif are among them. Both completed medical school in other countries and now live in Rochester, working at the Mayo Clinic, though not as physicians. They’re also both struggling to get matched into U.S. residency programs.
Lopez de Padilla came to Minnesota in 2001 after completing medical school and a residency in internal medicine in her home country of Venezuela, lured by the chance to do a three-year postdoctoral fellowship at the Mayo Clinic studying rheumatology and immunology.
Initially, Lopez de Padilla planned to return to her home country to practice medicine. Instead, she met her future husband. Along with marriage came kids, and the prospects of returning to Venezuela grew more distant by the year. She currently works at Mayo Clinic as a research associate in the musculoskeletal gene therapy lab.
She still wants to work in the United States as a physician, however, and is currently preparing for her second residency, which is required in the U.S. because the accrediting agency that certifies medical programs doesn’t recognize most foreign residency programs. (In the U.S., residencies come after four years of medical school and consist of years of specialization in a hospital or clinic working between 60-80 hours per week.)
To people like Lopez de Padilla, the prospect of doing it over again can be daunting. Still, she acknowledged that U.S. hospitals and clinics have legitimate “concerns and fear about who they’re bringing into the system.”
“I wish the system would work in a different way, but at this moment this is the rule,” she said.
Lopez de Padilla has since taken three MLE exams, or steps, and completed three clinical rotations. She said her test scores “were within the average for U.S. physicians” but acknowledged that, as an international medical graduate, “you need to stand out.”
Abdelatif is in a similar situation. He grew up in the United Arab Emirates and attended medical school in Sudan. After completing rotations in internal surgery and obstetrics, he became disillusioned with Sudan’s medical system. “The doctors there are fantastic, their knowledge is incredible, but they’re working in subpar conditions,” he said, recalling times when his hospital run out of routine items like saline solution.
Abdelatif set his sights on the U.S. because he wanted to be trained here, and because he already had family in America. Initially, he landed in California, living with his aunt while studying for MLE exams. The following year, he moved to Rochester to shadow a doctor at the Mayo Clinic for no pay.
To make money, he worked jobs at Target and Cub Foods and eventually landed a job as an EKG technician at the Mayo Clinic, where he continues to work today.
Like Lopez de Padilla, Abdelatif is now more than five years removed from graduating medical school. He also said his MLE test scores, though passing, “weren’t fantastic.”
Over the past five years, he’s applied to hundreds of residency programs and found no luck. This year, he applied to more than 140 programs. He’ll know if he matches into one by next spring.
But Abdelatif is also facing another hurdle: His time is running out. In his five years in the United States, he’s lived under temporary protected status (TPS). The Department of Homeland Security plans to remove Sudan from the TPS list next year, which means Abdelatif won’t be able to renew this status when it expires next November.
If he can’t get a green card or visa between now and then, he said he’ll be forced to return to Sudan, where he never made a backup plan should his medical career in the U.S. fall through. “That’s been on my mind for a while,” he said.