Where does it Hurt?

“Where does it hurt?” As a surgeon, I often ask new and established patients this question as a diagnostic tool and a way to communicate empathy. I want to know how I can help and to do that, I need to know the quality and character of your pain — dull or sharp, constant, or intermittent. An experienced physician can make much of the diagnosis from just the story of your pain.

Pain is personal and subjective, and only you, the patient, can tell me about your pain. As a pediatric doctor, I must remind parents that, as much as possible, I need to get this information from their child. I often look with a jaundiced eye as a mother is describing their child’s pain as a 10/10 (needing morphine NOW). At the same time, I watched that same child be so engrossed in their phone that the hospital could explode around them, and they would not look up (this is not 10/10 pain and I rarely prescribe narcotics).

My son once asked me after he broke his arm why we needed to feel pain, and as I comforted him, wishing I could remove all his pain, I explained that pain was necessary for our survival. It is educational and protective.

Don’t touch the hot stove! The memory of that second-degree burn is an effective teacher.

“Don’t date boys in rock bands who wear leather pants” (not as effective, but the pain was just as educational).

But pain can also change your personality, making what was tolerable unbearable. If it continues too long, it can turn the meek into monsters.

Being Black in America is to know pain, and it is constant and weathering. If you let it, you can be transformed into someone and something unbearable. Someone who lacks tolerance for anyone else’s pain and sees enemies everywhere.

Recently, I was asked if the new laws regarding International Medical Graduate (IMG) training made me mad? Did I feel that IMGs were being treated better than US-trained Black Physicians?

The change for IMGs is a response to the physician shortage created by the double blow of COVID-19 and the social phenomenon of the Great Resignation that followed as people’s priorities shifted in the wake of so much death. Many learned they could be just as productive at home without a bra as in the office. The first to act was Tennessee. In April of 2023, Gov. Bill Lee signed a law allowing experienced IMGs who have received medical training outside the US to skip prior residency requirements and obtain a medical license. After 2 years, if the physician remained in good standing, the Tennessee medical board would grant them a full and unrestricted license to practice in the state.

This was groundbreaking. In the past, the only way for IMGs to practice medicine in the US was to first obtain a categorical spot in an ACGME-recognized residency program. Once received, they were required to repeat their ENTIRE residency — even if they had been practicing for years in their native countries. Once completed, the last step was to pass the USMLE (United States Medical Licensing Exam).

To fully understand how much of a hurdle that was, in 2023, there were approximately 43,000 US medical school graduates for the only 40,375 available residency positions. Even without the addition of an IMG, in 2023, 2500 US-trained graduates did not match in residency spots.

Difficulty getting a residency spot or being unable to afford to repeat the education and training they had already completed in their home countries led many IMGs to take jobs in different fields to feed their families. This is why my last Uber driver in Florida was a Cardiothoracic surgeon from Columbia who had been in the US for 6 years trying to get a residency position to be able to return to work as a surgeon.

The irony is that like the current gender imbalance in China created by the one-child policy, which led to China’s daughters not being born by choice or adopted away to foreign lands; the US physician shortage is also a monster of their own making.

Forty years ago, a physician SURPLUS was predicted. Organizations like the Pew Charitable Trust and the Institute of Medicine (now renamed the National Academy of Medicine) urged a moratorium on new medical schools and a reduction of first-year residency spots to restrict the entry of foreign medical graduates into the US. In the 1990s, the government began paying hospitals NOT to train doctors to slow the number of physicians produced.

So, for 25 years between the years 1980 to 2005, as the US population increased by 70 million, the number of graduates from allopathic medical schools (MD not osteopathic, which train DO physicians) remained unchanged at approximately 16,000 spots per year, and the number of first-year positions only increased to 23,000. While the moratorium on US medical schools was meant to restrict the entrance of IMG into the US, during that same time frame, the number of IMGs in US residency programs doubled. Now, 1 in 5 physicians practicing in the US was born and educated outside of either the US or Canada.

I was fortunate to train alongside many gifted IMGs at SUNY Downstate in Brooklyn. These were fully trained surgeons who had to start over just to be allowed to work over 80 hours a week in one of the busiest trauma hospitals in the US. I often joke that one of the best things about my program is that I learned how to swear in 4 languages (Arabic, Mandarin, Russian, and Spanish). But in fact, working alongside these surgeons was a gift. They elevated my abilities by raising the bar.

So, as the US scrambles to address its self-created crisis, I am grateful for that past and applaud this decision as it was a long time coming. No such restrictions exist in medicine in comparable first world countries like Canada, Australia, or the European Union.

First, American medicine’s gatekeeping of the “best medicine in the world” has yet to improve outcomes in critical health markers for its Black population, such as maternal and infant mortality. We need fresh blood and a new perspective.

Second, many IMGs look more like me than White Americans.

Third, they are not the enemy. Equity in medicine is not just for one group and means nothing if we just create a new war of US-trained vs. IMG.

Fourth, state licensing restrictions already make it difficult for physicians to provide care. Except for a small number of states that offer reciprocity, each state requires that physicians apply for and obtain a state-specific license. Depending on administrative backlogs, worsened by the staffing shortages created post-COVID this requirement can take months and thousands of dollars to obtain.

Systemic racism is still flourishing in American medicine, but bureaucracy is also alive and kicking. It is tedious and painful and both work in tandem to cause mortal wounds to physicians of color and their patients and slow progress.

So, the question is not just “Where is the pain?” but “Where does it hurt the most?” I can’t tell. However, I know that providing more trained physicians, especially those willing to work in underserved areas in the United States, can only help, not hurt.

Welcome brother or sister, we already have patients waiting.