Good Intentions

Will New Licensure Rule Help or Hurt Access? 

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Medical Education Feature – December 2012 

Tex Med. 2012;108(12):53-56.

By Amy Lynn Sorrel 
Associate Editor  

A new state law that took effect Sept. 1 requires certain non-U.S. citizen physicians to practice for three years in a federally designated underserved area in Texas if they want a full Texas medical license. Legislators intended to boost the ranks of physicians in areas where doctors are scarce, but it remains to be seen if those objectives will come to fruition. Some physicians and licensure experts fear the additional requirement could unintentionally scare away a population of physicians that historically has helped fill access gaps across the state.

Roughly 14,000, or 23 percent, of the more than 62,000 licensed physicians in Texas are international medical graduates (IMGs), according to 2011 Texas Medical Board (TMB) figures. Experts say it is difficult to nail down what percentage of them are noncitizens, in part, because the board previously did not have to document applicants' citizenship status.

Nevertheless, IMGs comprise a significant enough portion of the physician workforce that the Lone Star State cannot afford to lose a single one, says Houston internist Maria Carmen Sarino-Roy, MD, a member-at-large of the Texas Medical Association's International Medical Graduate Governing Council. Both she and her husband graduated from medical school in the Philippines.

Adding mandatory service "could make it unattractive for physicians who may intend to set up practice in Texas. They are going to search elsewhere," where the requirement does not exist, she said. "If that happens, it could eventually exacerbate rather than help physician shortages here in Texas."

At the same time, with roughly 300 federally designated medically underserved areas (MUAs) and 400 health care professional shortage areas (HPSAs) in Texas, the pool of physicians targeted by the law alone is likely too small to shoulder the burden of reducing the need in those areas, Dr. Sarino-Roy adds.

Texas licensed a record 1,139 new IMGs in fiscal year 2012, according to annual figures from TMB, though experts attribute the spike, at least in part, to a rush on the system by many to avoid the new service obligations.

TMB is responsible for implementing and enforcing the statute, and TMA worked with the agency during the rulemaking process to win some changes that afford physicians some flexibility under the requirement. Meanwhile, TMA continues to monitor its effects.

"The law was passed with the intention of getting doctors to underserved areas, and TMA certainly supports that effort," said Darren Whitehurst, TMA's vice president for advocacy. "But we remain watchful, and if there are any problems, we will work with the Texas Medical Board to ensure that we have a law that makes sense."

Piling On  

Under the law, physicians who are not U.S. citizens, permanent residents, or conditional permanent residents and seek to work here – typically with an H-1B temporary specialty work visa – now must practice full time for three years in an MUA or HPSA to obtain a full medical license. That can include employment at federally qualified health centers and rural health clinics with a HPSA designation, according to TMB's newly adopted rules.

Noncitizens who either trained in Texas for at least one year before Sept. 1 under a postgraduate training permit or practiced under a temporary or limited license are exempt from the requirement, as are those who applied for full licensure before Sept. 1.

For this new requirement, TMB rules define active full-time practice as a minimum of 20 hours per week for 40 weeks in a given year. The regulation gives noncitizen physicians the option to work concurrently in another place if they so choose, as long as they fulfill the underserved area service requirement, says TMB Executive Director Mari Robinson.

"The rules were meant to make sure that the basic requirements of the law were enacted. So if it was not required, we were not going to be adding to it," Ms. Robinson said.

The three-year clock generally starts ticking from the time TMB approves an application, she says. Residency training in an underserved area counts toward the service requirement. And those who are employed at an institution that maintains a graduate medical education (GME) program, for example as a professor, are excused from the three-year service obligation.

But the new rule also comes with documentation requirements that apply to all physician licensure applicants.

Those physicians who are U.S. citizens, permanent residents, or conditional permanent residents must present acceptable proof of their status when applying for Texas licensure. Applicants subject to the mandatory service requirement must submit an affidavit of their intent to practice full time in an underserved area, such as an employment agreement, and they must eventually prove that they completed the three-year service.

TMB details these documentation requirements online.

Noble Beginnings 

State Rep. John M. Zerwas, MD (R-Simonton), who cosponsored the law along with Sen. Jane Nelson (R-Flower Mound), says it was an opportunity to drive some physician presence into underserved counties.

"Clearly, there is a deficiency in physician supply across the state, more in certain areas than others," he said. "The focus tends to be on primary care, but all physician specialty groups are in demand."

Rural areas like West Texas, as well as the Rio Grande Valley and border regions, for example, remain challenged to recruit physicians, Dr. Zerwas says. But even Waller County, part of the Houston metropolitan area he represents, is a designated MUA. 

Because Texas has a friendly practice environment, the requirement is unlikely to deter many IMGs from applying for licensure, Dr. Zerwas says, though lawmakers weighed such concerns when they considered the legislation. "There is no one-size-fits-all solution to the physician shortage, but this is one of the ways we can address some of that problem and get a little bit more mileage out of our H-1B visas."

Proponents say the law also creates parity with the federal J-1 visa waiver program. That program allows foreign medical graduates who complete their residencies in the United States to stay and work by committing to practice in an underserved area for three years, in lieu of returning to their home country for two years as their student visas require. Because federal law caps physician J-1 visa waivers at 30 per state, however, a disproportionate number of IMGs began seeking H-1B work visas instead, which previously had no service obligation.

Connie Berry, manager of the Texas Department of State Health Services Primary Care Office, said the law "levels the playing field between the two visa types and gives us one more tool for addressing the maldistribution of physicians."

Her office monitors the need in underserved areas in Texas. She also oversees the state's J-1 visa waiver program, known as Conrad 30, through which physicians have had success finding placement and good experiences with the communities and employers they work with.

Those factors, Ms. Berry says, contribute to the continual interest in the J-1 waiver program and physician retention in Texas, and could translate to similar success under the new H-1B visa licensure requirement.

Not What They Intended? 

Physicians and TMA staff say some of the TMB provisions, such as the definition of full-time practice, may help mitigate potential problems with the new law. Credit for residency in an underserved area also may help keep doctors in those communities and throughout Texas.

But the law may invite other unintended consequences, some physicians and licensure experts warn.

Dr. Sarino-Roy says the law overlooks some potential limitations on specialty practice in the designated underserved areas.

The federal government designates HPSAs and MUAs largely based on primary care and mental health shortages, among other factors. That means an IMG who has trained two or more years in a specialty field could be required to spend three years practicing primary care before obtaining full licensure in Texas, Dr. Sarino-Roy says.

"This brings up concerns about the safety of medical practice for doctors who are not specifically trained for primary care or mental health," she said.

The number of residency program slots available continues to dwindle, as does the pool of noncitizen physicians applying for Texas licensure, she says. So the requirement might better serve its purpose and physicians if it applied instead to licensure applicants trained in a primary care specialty, regardless of their citizenship status.

According to American Medical Association data, the top specialties represented by the IMG population are internal medicine, anesthesiology, psychiatry, pediatrics, family medicine, obstetrics and gynecology, radiology, and general surgery.

But even specialists who are able to fill a void in an underserved area may not have access there to the facilities they need to keep up their skills, says Denise Meyer, a former team leader in licensure at TMB and a physician licensure consultant.

The law could be a boon to many rural areas that have difficulty recruiting medical professionals, she says. But some regions and facilities could be left out.

"There are plenty of midsized hospitals out there in the middle of Texas that rely on IMG recruitment. But they are in areas not designated as MUAs or HPSAs and do not have a GME  institution around them, and they could be potentially harmed," Ms. Meyer said.

And with more than 4,000 license requests a year, the board could have its hands full with additional documentation checks "that could affect the time it takes to process an application," she added.

Legal implications may lurk, too.

The 2nd U.S. Circuit Court of Appeals in July struck down as unconstitutional a similar New York measure that barred noncitizen physicians and other health professionals from obtaining full licensure unless they secured a three-year waiver to practice in a medically underserved area.

The court in Dandamudi v. Tisch said the rule was discriminatory.

Texas and New York are the only states known to have such requirements, according to data from the Federation of State Medical Boards.

The TMB's Ms. Robinson said it's too early to know the new law's full impact. Because the requirement just took effect, however, most current noncitizen physician applicants are likely exempt.

"This is a new requirement for the board, too. Hopefully it will not be problematic, but we'll know better in a few months," she said.

Amy Lynn Sorrel can be reached by telephone at (800) 880-1300, ext. 1392, or (512) 370-1392; by fax at (512) 370-1629; or by email. 


WANTED: Physician in Underserved Area 

Noncitizen physicians subject to a new three-year service requirement in an underserved area before getting full licensure in Texas are not on their own to find a job.

The Texas Department of State Health Services Primary Care Office (TPCO) is available to help. Physicians can contact TPCO by email or by phone at (512) 776-7518.

Search federally designated medically underserved areas and health professional shortage areas in Texas at, which includes links to maps from the U.S. Department of Health and Human Services Health Resources and Services Administration.

Doctors also can browse for Texas jobs at:  

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