The neocoloniality of who cares: US underinvestment in medical education exacerbates global inequitiesBMJ 2020; 371 doi: https://doi.org/10.1136/bmj.m4293 (Published 17 November 2020) Cite this as: BMJ 2020;371:m4293
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Re: The neocoloniality of who cares: US underinvestment in medical education exacerbates global inequities
I read this essay with great interest. While the authors do an adept job of explaining several problems due to the current underinvestment in US medical education and rightly proposing changes such as increasing medical student enrollment, Graduate Medical Education (GME) residency positions (and funding) available in the US, they disregard three main issues, which cause misrepresentation that the US and other developed nations exacerbate the need for much needed physician workforce in developing countries by importing (or ‘siphoning’ as the authors call it) their leading physicians. The authors:
1: Do not recognize the root cause of the problem regarding why the leading international medical graduates (IMGs) want to pursue further training in the US,
2: Cause a potential misunderstanding of the percentage of foreign medical doctors from India who are accepted for further training in the US vs continue to practice in India by using the term ‘siphoning’ and sharing the statistics of the graduates of the top Indian medical school, rather than the total number of physicians who leave India vs total number of medical graduates from India per year.
3: Do not acknowledge how IMGs can help their country of origin and humanity at large by training and practicing in the US.
‘Siphon’ is defined by the Cambridge Dictionary as: “to take money, especially dishonestly, and use it for a purpose for which it was not intended”. Unfortunately, the authors, by not recognizing these three main reasons, and potentially the results behind this movement of physician workforce, use this negative term and argue that the US is siphoning off lifesaving workers from developing nations. Therefore, I decided to write this letter to argue that they are wrong in this characterization. As a final year medical student from Istanbul, Turkey (a developing country), leveraging my experience both in the US and in Turkey, I can attest that the leading reasons why leading IMGs want to train abroad are the problems at home; such as the lack of adequate structured residency/fellowship training positions to quench one’s passion for expertise, inadequate research opportunities and infrastructure to hone skills to become experts, and the concerns regarding the lack of a foreseeable career security, which are all compounded by corruption/mismanagement at the country of origins, rather than being ‘siphoned’ off. It is important to highlight that nobody is being siphoned off, rather, the leading physicians choose to and are effectively forced to leave due to lacking local opportunities.
Even though securing a residency position in the US is cumbersome due to the requirement of passing several qualifying exams, physically attending to residency interviews, and is therefore an extremely expensive process for those coming from low-income countries, still, physicians with an immense passion for solid training and means choose to take on this challenge/opportunity. In their article, the authors cite that about 51% of the graduates of the top ranked Indian medical school, All India Institute of Medical Sciences New Delhi left India, and characterize this as a reason causing potential harm to Indian patients. On the other hand, the authors ignore the absolute number of physicians this school graduates. That same cited article states that this school only accepts 45 applicants with an acceptance rate of about 0.15%, which makes this medical school far more competitive than any US medical school including Harvard, Johns Hopkins or Stanford, the leading American medical schools, which also represents limited local opportunities. India has a population of more than 1.3 billion people, and graduates about 67,218 physicians a year, and has already achieved the World Health Organization recommended doctor to population ratio of 1;1,000.  While the authors use the phrase ‘siphoning lifesaving workers to the US’, US National Residency Matching Program data published in January 2014 indicate that only 754 Non-US IMG physicians from India received admission to the US GME positions that year, which corresponds to about 1-2% of the yearly total physician graduates of India. Therefore, the characterization of the authors is subject to selection bias, lacks external generalizability, and represents the lack of opportunities to the most talented physicians in their home countries, rather than them being siphoned off.
The third neglected issue is that many IMGs who come to the US despite many obstacles represent the brightest of the countries they represent, and giving them the opportunity to train and practice in the US causes benefit not only to American patients, but also to the whole world by uncapping their potential and allowing them to conduct biomedical research in the US, and share their earnings with their loved ones back home. In their article, the authors argue and express dissatisfaction that Indian tax-payer funded medical school graduates are leaving their home countries and this is leading to a vicious cycle. Although how much IMGs financially contribute to their country origin is not separately known, immigrants in the US are known to contribute financially to their countries of origin; with over $30 billion USD to Mexico, $11.72 billion to India, and $11.30 billion to Philippines per year. According to International Association of Independent Accounting Firms, in 2013, India received $72 billion in remittances. Therefore, it begs the question: Could these immigrants and physicians have been as helpful to their home country, if they were to stay in their country of origin? Would it be fair from equal opportunity point of view to limit their entrance to the US medical system and deny them this opportunity? Besides the direct financial contribution, the immigrant physicians know and tend to be in contact with their colleagues in their home country, and help train the physicians in their home country through disseminating information via attending to congresses, facilitating clinical training and research through exchange programs.
Therefore, whereas the authors’ argument that the US critically needs more medical student and GME residency positions is well-supported, their argument that the US and other developed nations are exacerbating the development efforts in the countries they import medical graduates from is not supported by actual data.
1. Kaushik M, Jaiswal A, Shah N, et al. High-end physician migration from India. Bulletin of the World Health Organization 2008;86(1):40-5. doi: 10.2471/blt.07.041681 [published Online First: 2008/02/01]
2. Kumar R, Pal R. India achieves WHO recommended doctor population ratio: A call for paradigm shift in public health discourse! J Family Med Prim Care 2018;7(5):841-44. doi: 10.4103/jfmpc.jfmpc_218_18
3. https://www.nrmp.org/wp-content/uploads/2014/01/NRMP-and-ECFMG-Publish-C... . Published in February 2014. Access Date: November 18th, 2020.
4. https://www.forbes.com/sites/niallmccarthy/2019/04/08/immigrants-in-the-.... Published on April 8th, 2019. Access Date: November 18th, 2020.
5. https://www.inaa.org/migrant-remittances-the-impact-of-immigrants-sendin.... Published on March 18th, 2020. Access Date: November 18th, 2020.
Competing interests: No competing interests