Doctors Without Borders

That’s right — they’re not from Texas. Newly licensed doctors enlisting to treat the state’s Medicaid and Medicare patients are more likely to have been trained at international medical schools, according to a review of state medical licensing data.

Of the roughly 1,500 doctors who have received fast-tracked licenses in the last three years in exchange for agreeing to treat the state's neediest patients, nearly 40 percent were trained at international medical schools — everywhere from India and Mexico to Uzbekistan and Rwanda — while a quarter were trained at Texas medical schools. The Texas Medical Board fast-tracked more licenses for doctors trained in Pakistan than it did for those educated in Louisiana or Oklahoma. (Scroll over our interactive world map to see where these internationally trained doctors got their medical education.)

Internationally educated doctors are nothing new in Texas. Doctors trained outside the U.S. or Canada already make up more than a fifth of the state’s licensed physicians and more than a quarter of the new doctors licensed every year. They’re essential to the state’s medical workforce; in the midst of a national primary care shortage, they sustain everything from Texas’ public health clinics to its rural doctors’ offices.

“The impact is not only in Texas, but nationwide,” says Dr. Ashok Kumar, the president of the Texas Academy of Family Physicians and an international graduate himself. “These are the doctors who are going to serve Texas’ rural patients, urban patients, underserved patients.”

As more longtime doctors stop seeing money-losing Medicaid and Medicare patients — the result of far-from-adequate federal and state reimbursement rates — the burden will increasingly fall to these international medical school graduates. Many of them have visas that are contingent upon their work with poor and underinsured populations in cities and small towns. With health care reform expected to push an estimated 1 million new Texans onto state Medicaid rolls, the pressure on the doctors who do accept these patients will only mount.

International doctors come to Texas because it’s a big state with a lot of opportunities but also because they’re recruited here. Medical schools, Veterans Affairs hospitals or group practices in search of a particular kind of physician often help international graduates get visas, sometimes with strings attached.

To get licensed in Texas, these graduates must go through a rigorous and lengthy process, including getting three years of post-graduate training in the U.S. and proving that their medical education was “substantially equivalent” to the education provided in a school here or in Canada. Many international schools are already pre-approved. Others require mounds of paperwork, and months upon months of review — which Kumar says leads some young doctors to flee to states with less-stringent licensing procedures.

So when the Texas Medical Board offers to help doctors cut through the red tape in exchange for their agreement to take government-subsidized patients, it’s no surprise that many international graduates jump at the chance. “They self-select to do that, because they know their applications as a rule take longer to process,” says Jaime Garanflo, the medical board’s director of licensure.

Agreeing to treat Medicaid and Medicare patients, or to practice in an underserved community, is also a fast way to build a practice and build credibility, says Jose Camacho, executive director of the Texas Association of Community Health Centers, which represents providers and federally funded clinics that treat the uninsured and underserved. But Camacho says these doctors vary in their success — and that sometimes the cultural barriers they face are insurmountable. In one case, a Middle Eastern doctor came to practice at a federally financed clinic, only to realize the facility’s executive director was female. He left, saying that, in his country, men didn’t take orders from women. On the other end of the spectrum, Camacho says, is an Indian doctor placed in Brownsville who learned to speak Spanish so he could communicate with his patients and found ways to get Indian spices mailed to him from Texas’ big cities so he never felt too far from home. 

“We often talk about being culturally sensitive to our patients,” Camacho says. “The reverse is also true. We have to be culturally sensitive to the providers’ needs.”

Kumar knows this firsthand. Kumar went to medical school in India, completed his surgical residency in England, then came to the University of Texas Health Science Center at Tyler for his family medicine residency. After a short stint practicing in Oklahoma, he came back to practice in Texas. Today, he’s the director of medical student education at the University of Texas Health Science Center at San Antonio. He said he and his family practice colleagues, particularly those working with underserved patients in remote areas, have been completely embraced by their communities.

“When I came here, it was — both weather-wise and culture-wise — a little bit of a shock,” he says. "But anyone has to acclimatize."