Refugee Docs Forced to Start Over to Practice in US

Shoshana Akabas

April 06, 2021

Last spring, physician Faariah Bashir scrolled through job openings, looking for a way to use her medical degree and years of clinical experience to support the fight against COVID-19 in New York City. But with each job listing, she hit the same roadblock: Despite years of trying, she's still not licensed to practice medicine in the United States. So, as physicians across the country struggled in resource-limited hospitals throughout the spring and fall, Bashir was stuck on the sidelines.

Bashir, who asked to be identified by a pseudonym, is one of approximately 165,000 internationally trained healthcare professionals living in the United States who are not currently working in the healthcare sector, according to data from Migration Policy Institute. This enormous gap is in part due to the arduousness of the relicensing process in this country — especially for refugees who are starting over in America. Advocates point out that unleashing this unique workforce would have a lot of benefits, especially given that the American Association of Medical Colleges estimates a shortage of up to 139,000 physicians in the United States by 2033.

As it stands, relicensing is easier said than done: it takes an average of 10 years for a foreign-trained doctor to be relicensed in the United States, and few are able to overcome all the hurdles. "You have to have time, and you have to have money," says Bashir, and right now, she has neither.

As a high schooler in Libya, Bashir earned top grades, and her parents encouraged her to pursue a career medicine. "We have much deficiency in our country's medical field," she says, and she was eager to contribute where she was needed most.

She attended Al-Arab Medical University (now called the University of Benghazi) and earned her degree in medicine and general surgery. She completed clinical rotations, passed licensing exams, and began practicing obstetrics and gynecology.

Workdays at the Al Joumhouria Benghazi Hospital were long but rewarding. She spent her days providing medical care to patients with fibroids, postmenopausal bleeding, miscarriages, placenta previa, and preeclampsia. Premature rupture of membrane and premature labor were both common. Her heart ached for some of the patients with dire conditions whom she encountered — like a young woman who came in requiring a hysterectomy — but she thrived off the feeling of assisting patients and seeing them improve.

As a result of her high grades and success in the field, she received a scholarship to continue her training overseas, and she chose to come to the United States to pursue a masters of pharmacology and toxicology from Long Island University, in New York. When she left in 2007, her home country was relatively peaceful. "Libya was quiet," she says. "There was no war at the time."

But by the time Bashir completed her master's program, the Arab Spring had torn through the neighboring countries of Egypt and Tunisia and had settled in Libya. From across the ocean, Bashir and her husband followed the protracted ousting of Libya's leader, Muammar Gaddafi, and the steady increase in terrorist attacks. As the country plunged back into civil war, it became dangerous for them to return. Bashir realized they were stuck in the United States.

Bashir took on a job as a pharmacy technician to help support them, and as they worked to make United States their new home, Bashir decided to try to rebuild her medical career in America and to apply for recertification.

Financial Hurdles

Internationally trained doctors must redo their residencies to practice in the United States. Even before applying, they must have letters of recommendation from a US-based doctor, and most applications require clinical experience in the United States — none of their foreign work experience counts.

Having to start from the beginning can be the most frustrating part for refugees pursuing their former careers in any sector, says Yalda Afif, a program manager at HIAS, a Jewish nonprofit organization that helps resettle refugees. "Ten or 20 years of experience working back home — that's not considered, and they're not given any kind of credit," says Afif. "They feel like, 'We don't have any value for the work we did, the education that we have.' "

Clinical volunteer slots can be particularly difficult for refugees to secure, because they often go to students in US medical programs or to those with networks and connections. Bashir had neither, but after searching, she decided to approach her children's pediatrician about volunteering at the clinic.

Although taking measurements and vitals is far from utilizing the depth of her medical training, she's found the experience helpful for learning about illnesses that are more prevalent in the United States but less common in Libya, such as Lyme disease. Her time at the clinic has also taught her some of the ins and outs of the relatively complicated American medical system. "We don't have insurance in Libya," Bashir explains. "We have public hospitals and some private clinics. So even this, I need to be familiar with."

Bashir is lucky to have found such an opportunity. "There's a whole economy around charging these doctors to have access to opportunities to get placements," says Jina Krause-Vilmar, president and CEO of Upwardly Global, a nonprofit organization that helps immigrants and refugees restart their careers in the United States in their fields of expertise. The clinical roles are unpaid, Krause-Vilmar says, but in some cases, "you're not able to secure one and have to pay a third party in order to help you secure a slot to work for free." Companies can charge thousands of dollars in exchange for clinical placement and assistance navigating the US licensing system.

Newly arrived physicians with families often can't afford to work for 3 months without pay. Most refugee families bring very little with them and are overwhelmed by living expenses and other costs, such as paying back the International Office of Migration for their initial plane tickets to the United States, especially because their government resettlement stipend is only $1125 per person (which usually goes toward rent). Facing 3 months without pay while working as a clinical volunteer isn't the only financial hurdle doctors in Bashir's position must overcome.

Bashir has saved up for years to pay the STEP exam fees, which each cost $975. Every time Bashir dipped into her savings to buy food or clothes for her kids, the STEP exam fees got a little further out of reach. Krause-Vilmar, of Upwardly Global, says there are no standard scholarships offered for people in Bashir's position, and it's heartbreaking to see doctors save up for long periods just to be able to take the exams. She witnesses this problem time and again with her organization's clients, like a Burmese couple — both physicians — who worked for years in the kitchen of a sushi restaurant before they had enough money in their bank account to pay for the tests.

The fees, which Bashir says have risen every year, don't include study materials, transportation to the exams, and other costs.

Financial problems are just one of many barriers that can pop up for applicants. Providing proof of medical training received abroad, which is another relicensing component required before one is able to sit for the exams, can take months or even years. If the university in a war-torn country is closed, it can be extremely difficult to verify that refugees' transcripts are valid and that they have earned their diplomas. Applicants can also incur other fees, such as paying to have their foreign documents officially translated to English.

Many of these components are completed through the Educational Commission for Foreign Medical Graduates (ECFMG), the organization responsible for the primary source verification required of any doctor who attended medical school outside the United States. Although the ECFMG often receives confirmation from international schools within 30 days of requesting documentation, some institutions in countries that do not have diplomatic relations with the United States refuse to cooperate and release records, and other institutions no longer exist, owing to turmoil in the country.

"It's just a long process in terms of communication with their home countries' medical schools," says William Pinsky, MD, president and CEO of ECFMG. "The ones that get through the process, get certified, and go on through training show remarkable resilience."

An Unwelcoming Destination

Having to complete all of these steps — document verification, STEP exams, volunteer clinical work, and repeating residency (often 1 to 3 years) — helps explain why the relicensing process takes a decade for many doctors.

Advocates such as Krause-Vilmar are pushing for systematic changes that could help eliminate some of the hurdles for refugees and asylees — but many of the changes must be made by individual states' licensing boards. "We would love to see states...allowing these individuals to be fast-tracked by working under registered doctors so that they can get experience and they can demonstrate the quality of their work," says Krause-Vilmar. "We absolutely understand the need to ensure the integrity of our medical professionals. We're challenging the system to think of ways for individuals to demonstrate the quality of their work that doesn't take 5 to 10 years."

Even after overcoming the barriers to relicensing, the system that awaits refugees on the other side of the exams can be unwelcoming. Bashir has a friend who went through the whole process but couldn't secure a residency match.

Bashir was finally able her to take the first STEP exam in February, but she's nervous about securing a position in a hospital. She, like many refugees, comes from a country where medical training is part of a centralized government system that places candidates in residencies and jobs. As a result, they don't have experience with an extensive application process, have never had to market themselves, and are unused to interviewing. In a country like the United States, where the vast majority of jobs are secured through personal connections, arriving as a refugee without a network is a huge disadvantage.

On the other side, potential employers who have gone through the American system themselves look at a candidate's training in residency programs within specific hospitals for a way to certify approval for their skills or education. This works against candidates with foreign hospitals or schools on their resume, Krause-Vilmar says. "There is real bias against people who have foreign degrees and foreign work experiences; there's real bias against people who have an accent and are perceived as foreign."

But Bashir counts her foreign experience as an asset that will allow her to make a difference in underserved communities in America. "Because of our culture, some ladies just like to go to female doctors," explains Bashir, who has noticed that Arab women in her circle sometimes forgo medical care because they don't feel comfortable with a male doctor. Language barriers can also keep members of her community from visiting doctors. "They find it difficult to speak in the English language," says Bashir, "so they refuse to even go to female doctors."

Gaps in language and cultural competency in medicine can have detrimental effects, research has demonstrated. A 2020 study published in JAMA showed that children whose parents speak limited English are nearly twice as likely to suffer medical errors when hospitalized, such as incorrect dosing and allergic reactions to medications despite a known allergy. Medical professionals such as Bashir can increase access to culturally informed care and build trust between doctors and patients in communities where this trust is lacking.

Bashir's desire to serve families who may not otherwise feel comfortable seeking care has kept her motivated, and she eagerly awaits the day she can treat patients again, but the process has left her exhausted and discouraged. She's spent years saving, studying, and learning to navigate this new system, with the weight of uncertainty resting heavily on her shoulders. She worries that, in the end, it will all have been for nothing.

"You'll spend the time, you'll spend the money — a lot of money — and you don't know if you can get matched in the hospital or not. This is a long journey," says Bashir, "and when you start the journey, you do not know the end."

Shoshana Akabas is a writer, translator, and teacher based in New York. She has worked with refugees for nearly a decade and reports on refugee policy and issues of forced migration. Follow Shoshana on Twitter: @ShoshanaAkabas.

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