The post-1965 influx of migrants to the United States was different. This person was no longer an unskilled labourer, no longer the tired, or the poor, or part of a huddled mass;Footnote 1 they were trained experts responding to America’s call for assistance. Upon signing the Hart-Celler Immigration and Nationality Act into law on 3 October 1965, President Lyndon B. Johnson explained that this new migrant would ‘contribute most to this country – to its growth, to its strength, to its spirit’, and they would come to this country ‘because of what they are, and not because of the land from which they sprung’.Footnote 2 But this was the dilemma: what were they? Hart-Celler was responsible for shifting the kind of immigrant that would henceforth join the country, and bureaucratic proceduralism was delegated with excavating what they were.
Physicians were foremost on the list of immigrants considered valuable contributors, and specifically Asian physicians. This unique demographic configuration was a consequence of a confluence of political events – both international and domestic – that occurred in rapid succession. In the 1960s, amidst a particularly turbulent period of the Cold War, flashes of US vulnerabilities were exposed to the world. The Cuban missile crisis (1962) reminded the American public just how proximate the nuclear threat truly was, escalation of the Vietnam War renewed outrage over this progressively damaging quagmire, and civil rights demands and demonstrations continued to intensify daily. US politicians feared that recently postcolonial nations might view these events as missteps and lose confidence in the capitalist world order, and shift their allegiance toward the Soviets. Therefore, to prevent any red leanings, the United States would have to adopt a multi-pronged propaganda campaign, and immigration reform was one weapon in this arsenal.Footnote 3
Prior to Hart-Celler, the most comprehensive immigration law in the United States was the Johnson-Reed Act of 1924. Heavily influenced by eugenic thinking, this bill severely restricted immigration from Southern and Eastern Europe and prohibited Asian migration to the country. As Mai Ngai explains, the bill divided Northern Europe and the rest of the world and deemed ‘white’ persons from ‘white’ countries desirable future Americans.Footnote 4 By 1965, this position was diplomatically untenable. The United States could not persuasively appeal to postcolonial nations to join its sphere while simultaneously disallowing individuals from those very same nations entry into the country.
The need for immigration reform coincided with an urgent demand for medical labour. By the 1960s, the United States faced a critical shortage of health care professionals, prompting President John F. Kennedy to sign the Health Professions Education Act of 1963. The law provided construction grants to medical schools and financial aid for ‘needy students’ pursuing the ‘long and expensive training’ required to become physicians – measures Kennedy deemed essential as the nation’s most vulnerable populations, including the aged, chronically ill and mentally disabled, languished without adequate medical attention.Footnote 5 His successor, Lyndon B. Johnson, expanded these initiatives through the Civil Rights Act of 1964, which outlawed discrimination in public institutions and federally funded programmes, and through the creation of Medicare and Medicaid in 1965. These landmark programmes extended health insurance to more than 24 million Americans, sharply increasing demand for medical care. Yet hospitals, newly required to desegregate to receive federal funds, faced a surge in patients without a corresponding increase in physicians to treat them.
To address the gap, in 1965 Congress passed the Hart-Celler Immigration and Nationality Act, which eliminated race-based quotas and prioritized the immigration of skilled professionals. Amongst this cohort, Asian physicians were a key constituency. Not only did they serve a diplomatic agenda by allowing the US to showcase its friendly relations with postcolonial countries, but also these professionals could provide necessary medical labour almost instantly. But should they? Between 1965 and 1975, roughly 75,000 foreign physicians entered the United States, matching or exceeding the number of domestically trained doctors each year.Footnote 6 Initially met with hesitation, these physicians soon became indispensable to the US health care system. Over the past six decades, they have comprised at least a quarter of the nation’s doctors and an even greater share in federally designated health professional shortage areas, where the need for care is greatest.
Despite their prevalence and importance, a central concern persisted regarding these practitioners: do they truly possess the expertise they claim, and is that good enough? These anxieties revealed a tension in capital’s global aspirations, as the human elements of ‘human capital’ inevitably disrupted efforts to create a hypermobile, homogeneous medical labour force. Notably, such concerns were not evenly distributed across professions. For instance, the credentials of migrating scientists and engineers were more internationally recognized, which made the transfer of their expertise across borders different to that of physicians. In contrast, physicians faced rigorous scrutiny, with each country requiring strict verification of credentials and often demanding re-examination or retraining. This was largely due to medicine’s direct implications for patient life and death, compounded by the lack of global standards in medical training. As a result, being recognized as a physician in one country did not necessarily guarantee recognition in another. Given these challenges, what forms of coordination were needed to reconcile such differences and establish even a semblance of equivalency?
Versions of this problem exist across many domains. Scholars of standards, working from meteorology to medicine, have shown that standards are not benign technical artefacts; they are social technologies produced through institutions, instruments and consensus, carrying the social imprints of their construction. For example, as Coleen Lanier-Christensen shows, in the early part of the twentieth century, the Association of Official Agricultural Chemists (AOAC) succeeded in creating validated analytical methods for chemistry that relied on consensus around protocols that could generate results that were ‘uniform enough’. Only once procedures, assays and documentation were stabilized could chemical goods move efficiently through markets.Footnote 7 Nearly a century later, the AOAC sought to extend this model to toxicology by standardizing animal-based tests for chemical safety, but failed. Unlike chemical substances, biological organisms were infinitely variable, and toxicological expertise relied on individual judgement rather than mechanical reproducibility.
The tensions that Lanier-Christensen identified – capital’s demand for uniformity and biology’s refusal to comply – were exacerbated when standardizing human capital in the embodied form of medical professionals. Making people ‘uniform enough’ was not only a procedural challenge but also a political one, frustrating US regulators long before the arrival of foreign physicians. In the nineteenth century, the health care marketplace was decentralized and heterogeneous, encompassing a wide range of healers and practices. By the early twentieth century, elite white men trained in European-style medicine used the influential Flexner report to impose a standardized model of education and training, employing accreditation and licensing to exclude others. These reforms shuttered Black and women’s medical schools, consolidating medicine as an elite, white, male profession.Footnote 8 Under the alibi of ‘standards’, the medical establishment pursued a restrictive social agenda that embedded racialized and gendered hierarchies while defining who counted as a legitimate professional and what forms of knowledge were valued.
After the Second World War, however, standardization faced a new challenge. The arrival of Jewish émigré physicians exposed the limits of a system built to regulate only domestic production. Standardization could no longer be confined within national boundaries; it now had to account for training and expertise developed elsewhere. The US medical establishment had built a system capable of producing ‘uniform-enough’ physicians domestically, but what of these practitioners from elsewhere? How could their skills be assessed, validated and made commensurable with American medicine?
Eventually, the scale of the problem exceeded the existing bureaucratic infrastructure and prompted the rise of new international organizations to manage this transnational flow. While the United States was and continues to receive the largest number of immigrant physicians, other countries dependent on immigrant doctors, such as Canada, the United Kingdom and Australia, also joined these international regulatory bodies in hopes of deciphering and managing the global diversity of medical education. They relied on these organizations to help assess and standardize foreign credentials, allowing for a smoother integration of immigrant physicians into their national health care systems.
In the last sixty years, the migratory flow of health professionals from low-income to high-income countries has continued unabated.Footnote 9 In response, the international community has produced an expanding array of standards and compendiums to massage the movement of medical professionals from one context to another. Yet, in this proliferation of guides and regulatory bodies – largely designed by institutions in the global North to evaluate human capital from the global South – a hierarchy emerges in which knowledge from the North is presumed universal, while knowledge from the South is treated as local, incomplete or in need of retraining. The standardization of physician labour thus does more than assess technical competence; it enacts a geopolitical order that privileges certain epistemologies and racialized bodies as the standard-setters in the domain of care and others who are required to comply.
In this essay, I track three episodes in which US organized medicine grappled with the challenge of integrating foreign-trained physicians. Although these issues were global in scope, the United States served as a central driver of action and coordination. First, I examine the integration of Jewish émigré doctors during and after the Second World War, marking the profession’s initial confrontation with expertise from abroad. This episode is important because it reveals that organized medicine’s hesitations toward these practitioners differed in nature from the uncertainties that would later surround Asian migrants. Next, I explore the influx of Asian physicians following the Hart-Celler Act and the emergence of new mechanisms to manage their entry. Finally, I turn to the contemporary landscape, where international regulatory bodies attempt to impose order on the world’s diverse medical education systems. Through these episodes, the apparatuses charged with making medical credentials ‘uniform enough’ have multiplied, overlapped and expanded. Yet this proliferation has not resolved a fundamental issue: Dr Hakim Ahmed MD (India) is not the same as Dr Hakim Ahmed MD (America); they are ‘different objects’ under a single name.Footnote 10 Hakim Ahmed in India was a practitioner who had over five years of work experience as a pulmonologist. And Hakim Ahmed in the United States was a first-year resident starting basic clinical training anew. The same physician can be fundamentally reclassified as a different kind of expert when their credentials cross national and institutional boundaries. Thus moving medical expertise across political borders is never just a technical matter of licenses – it is an operation that redefines who counts as a physician and the terms on which they can be trusted.
First pass
The Second World War catalysed the initial wave of physician migration to the United States and posed the first challenge to organized medicine from physicians trained outside the country.Footnote 11 Due to the ‘European upheaval’, Jewish physicians, mostly from Germany, Austria and Poland, were forced to flee their home countries and resettled in America.Footnote 12 Many were highly trained in prestigious European schools, were aged between forty and fifty, and were experienced practitioners. In the United States, Jewish émigré physicians were unable to practise their profession since most states prohibited non-citizens from obtaining a medical license.Footnote 13 Frustrated with this gatekeeping in light of current political events, in 1939 a group of prominent US physicians formed the National Committee for Resettlement of Foreign Physicians to advocate for refugee physicians and assist in their ‘complete integration … to the American scene’.Footnote 14
The National Committee was a volunteer organization dedicated to convincing the American medical community that banning Jewish émigré physicians from practising in the United States was not only morally misguided, but also anti-Semitic. To achieve this, the committee provided comprehensive support for Jewish doctors. Their efforts included offering financial loans for things ranging from clothing to assisting with the costs of opening a new practice, providing English-language tutoring, lobbying the New York State licensing board to eliminate the citizenship requirement for medical licenses, and using members’ personal reputations to vouch for Jewish physicians and help them secure jobs, even in a hostile political climate.Footnote 15
In a report published in 1941, the National Committee chastised colleagues for their parochial attitudes, stating, ‘where once a medical degree from any noted European university was considered proof of outstanding scholarship, now there is a deplorable tendency to swing in the other direction’. The authors accused organized medicine of refusing foreign physicians admission into the profession in order to preserve their power by ‘building bars around their own small domains, arbitrarily cutting off those valuable immigrants whose professional ability could contribute to the health of the whole nation’.Footnote 16 Through these bureaucratic alibis framed around unknown educational standards, the US medical establishment was simply trying to preserve their elite position ‘from unfair competition from émigrés’.Footnote 17 Instead of prioritizing the health of the American public during a time when there was a physician shortage – a reality especially pronounced in rural communities – US physicians were exposing their self-serving agenda.
The committee declared three main objectives: ‘to evaluate the eligibility of individual émigré physicians to practice medicine’, ‘to assist those who were found competent for American medical requirements’ and to ‘further their resettlement’.Footnote 18 Enacting these goals, however, proved more challenging than was anticipated. Since states were the ultimate arbiters of medical licensure, there was no cohesive or coherent strategy to address Jewish émigré physicians’ professional entry into the workforce. Some states rejected these practitioners because they were not yet official US citizens, others rejected them on the basis of insufficient information about their education and quality of instruction in European medical schools, California denied licensure to all graduates of foreign schools unless the country in which the school was located had a reciprocity agreement with US licentiates, and still others required graduation from an American accredited school.Footnote 19
One of the great ironies of these restrictions was that, until a few years before Jewish physician migration began, the United States was grappling with its own quality-control issues. At the beginning of the twentieth century, US medical education was considered inferior to its European counterpart. It was unsystematic and haphazard, and lacked scientific rigour. The European model, in comparison, promoted a scientific approach to medicine combining medical education with clinical practice and laboratory knowledge. This was confirmed by the 1910 Flexner report, which surveyed the deplorable state of medical education in the US and recommended urgent reforms that included higher standards for admissions, curricular changes that emphasized a strong foundation in basic sciences, an emphasis on scientific research, affiliation with a university, and the closure of schools that failed to meet these standards.
Unlike in the European system, however, enforcing these reforms in the United States, which had a decentralized private educational system, was complicated. Organized medicine, most notably the American Medical Association, had to lean heavily on state licensing boards and medical societies to do much of the professional policing work. The AMA furnished lists of schools considered reputable to these administrative entities, which used the recommendations to approve licenses or deny hospital privileges. These gatekeeping strategies produced a homogeneous labour force of predominantly wealthy, Protestant, white men educated in seventy-eight schools across the country.Footnote 20
In a 1929 yearly report of educational data assembled by the AMA’s Council of Medical Education and Hospitals – the division that set standards and monitored medical schools – the final section is called ‘Foreign medical colleges’ and identifies 321 recognized medical schools outside the United States. This list includes schools in India, Africa (which was labeled as a country), Turkey, Chile, Japan and all European countries. The authors conclude that ‘American medical schools are now considered on a par with those abroad’ – finally.Footnote 21
To reiterate, it had taken about twenty years for organized medicine to implement Flexner’s recommendations – which were based on European standards – and establish a medical profession that had recognizable standards and licenses and a particular demographic constitution. Given this social and bureaucratic feat, the incorporation of Jewish émigrés was considered threatening. Yet, despite this reluctance, the National Committee for Resettlement of Foreign Physicians were motivated by a righteous obligation. They helped Jewish émigré physicians navigate state licensing exams, facilitated job placements and assessed their suitability for specific institutions.Footnote 22 Often frustrated by the inconsistent and onerous demands placed on these physicians to produce evidence of their expertise, committee members worked as dedicated advisers and liaisons between foreign physicians and the bureaucratic architecture, often vouching for these practitioners’ credentials and skills.Footnote 23 They understood their work as an urgent moral undertaking and the national committee was committed to being on the right side of history.
Round two
The work and even the need for the National Committee for Resettlement of Foreign Physicians reflected a complex issue that was being actively negotiated within the US medical establishment: how to verify the vigour and veracity of medical credentials in general, and specifically how to do this with credentials obtained outside the country. To this end, one of the major reforms to take place after the 1910 Flexner report was the creation of the National Board of Medical Examiners (NBME), a non-profit organization charged with creating uniform standards for evaluating medical knowledge and expertise, and the Federation of State Medical Boards (FSMB), an organization tasked with assisting states with licensure. The NBME’s mission was to evaluate credentials and administer an examination for licensure that states could use if they chose. This examination was considered an additional checkpoint to ensure that only the most qualified progressed into the profession.
By the 1930s, NBME members started to raise concerns about the first part of the mandate: evaluating credentials. In internal newsletters, they asked, ‘Are medical boards keeping pace with medical education?’ And in answering this question as it related to foreign medical graduates, no one was sure of the answer. Some state boards had experience with foreign physicians and could ‘estimate educational qualifications more readily, but a goodly number of state boards [were] unable to do so’.Footnote 24 Vermont Board official W. Scott Nay explained that one of the ‘annoying’ concerns his board faced was verifying the provenance of some of the credentialling documents they received and, as a result, requiring an affidavit certifying graduation from both the foreign and American consuls.Footnote 25 Other boards required direct correspondence with foreign medical schools, while others had no strategy whatsoever.Footnote 26
With all the variance and confusion, by the 1940s, and especially with the immigration of Jewish physicians, members of the National Board of Medical Examiners joined forces with the American Medical Association, and the American Association of Medical Colleges, to produce the most comprehensive list to date of foreign medical schools that should be recognized by state licensing bodies. The working list included approximately fifty medical schools located in Belgium, Brazil, China, Denmark, Finland, Lebanon, the Netherlands, Norway, Sweden, Switzerland, England, Northern Ireland, Scotland and Wales.Footnote 27 Graduates on this list could automatically proceed to sit for the NBME examination, which was now required by more and more states as a medical licensing requirement. If, however, a candidate wished to take the examination and received their education from an institution not on the list, they could only do so if an NBME committee member ‘had personal knowledge of the quality of their schools and only after completion of two to three years of postgraduate training or other experience in the United States deemed equivalent by the National Board’.Footnote 28 What these caveats make clear is that much of this early work to evaluate credentials and determine eligibility for medical practice continued to be contingent and discretionary.
To further complicate the matter, immigration was a central political tactic used by the United States during the Cold War to garner sympathies and reinforce the capitalist world order. However, as authors of a piece in the Federation Bulletin, the internal newsletter of the Federation of State Medical Boards, lamented, ‘The United States government, in fostering international good will, is admitting large numbers of displaced persons, including physicians about whose professional ability it asks no questions.’Footnote 29 This was a ‘serious menace’ to the whole enterprise.Footnote 30 Something more robust and systematic was necessary to manage this migration.
Overwhelmed by the task of developing a streamlined, comprehensive protocol to evaluate foreign medical graduates, in 1954 the NBME decided that the best way forward was to discontinue the admission of foreign physicians to its test for state licensure, even if the person attended a foreign medical school on the latest list of approved foreign medical schools. State boards were not equipped with the requisite knowledge to be the first point of contact for these immigrant physicians. Instead, the NBME, along with other interested parties, lobbied for the creation of a new organization that would operate as a ‘central screening agency’ that did the work of evaluating credentials and conducting a preliminary examination. Only after this step could foreign physicians enter residency training and eventually sit for state licensing exams.Footnote 31 In 1956, this new entity formally cohered into the Educational Commission for Foreign Medical Graduates (ECFMG), the primary regulatory body for foreign-physician migration.
The ECFMG’s task, like that of their predecessors, was to develop and implement a procedure that could convert the diversity of immigrant physicians with a range of education and training into practitioners deemed acceptable by US standards. The first step was developing an examination and the ECFMG relied on existing entities to assist with this project. Eventually, they settled on approximately 360 questions and an English component. The next issue was deciding how the examination would be administered. Would foreign physicians have to take the examination once they had arrived in the United States, or should they have access to it in their home countries?
These deliberations were unfolding during the height of Cold War soft-power campaigns, when educational and professional exchanges became pivotal instruments of American diplomacy.Footnote 32 To this end, President Eisenhower sanctioned the proliferation of US Information Offices in strategic non-aligned countries that would assist in shaping opinions amongst influential groups, including politicians, educators, journalists and students.Footnote 33 India and Pakistan, both newly independent and among the world’s largest democracies, were especially critical due to their proximity to Russia and China, serving as vital bulwarks against communist expansion. In these countries, US information offices were in major metropolitan centres; they established libraries, provided access to American media, hosted film screenings and helped facilitate educational exchanges.Footnote 34 For medical professionals, this usually occurred on an ad hoc basis with embassy officials making personal judgement calls about a visa applicant’s suitability for the US medical system.
John Hubbard, an architect of the first internationally administered ECFMG examination, explained that embassy officials
were already deeply involved in the problems of foreign physicians applying for positions in American hospitals and seeking United States visas. In fact, they, in general, welcomed a procedure that would provide a valid reason to refuse a visa to a physician with a medical background of uncertain quality and with little or no knowledge of the English language.
Additionally, Hubbard argued that having an examination was beneficial for students who may have attended a medical school that was not on any compiled list used in the United States. This was an opportunity to ‘demonstrate individual competence’ irrespective of educational background. It was an ‘evaluation of the individual’ rather an evaluation of the educational institution that they attended.Footnote 35 While Hubbard’s egalitarian ethos was commendable, in practice the ECFMG was still responsible for verifying and validating a foreign physician’s medical education and certifying that they received their training from a reputable, accredited institution. But again, the dilemma of accredited by whom and using which standards troubled the whole procedural enterprise.
The ECFMG turned to the World Health Organization (WHO) for guidance and used the WHO’s World Directory of Medical Schools as a tool to validate and evaluate a foreign physician’s educational credentials. First published in 1953, the World Directory was compiled in response to the increased transnational movement of skilled professionals and was the first comprehensive attempt to systematize global medical education. In 1956, the WHO published an updated second edition with data on roughly six hundred medical schools located in eighty different countries. It included basic information such as the address of the school, the year it was founded, whether it was public or private, and a basic breakdown of the curriculum.
In the introductory pages of the 1956 edition, the authors penned a notable disclaimer. Recognizing the enormity of their endeavour, they wrote,
No attempt has been made to draw firm conclusions or to make pronouncements on medical education as a world-wide phenomenon. The descriptive accounts and factual material which make up this Directory may be considered as part of the raw data on which the reader can base his own independent analysis; they are intended to be no more than a general guide, and investigators in the subject of medical education should not expect to find a complete report therein.Footnote 36
They explain that one of the most complicated aspects of this documentation process is the significant variation across institutions and geographies. For example, medical school is considered a four-year course of study in some places and an eight-year programme in others; premedical sometimes means secondary school, other times it begins in college, and in a few cases it begins after a bachelor’s degree is earned. Internship, which generally means clinical training, is likewise subject to a variety of different interpretations. ‘Several possibilities exist: (1) a certain period of hospital work occurs after the end of formal classroom studies; (2) hospital work is undertaken by the student during the clinical part of the medical curriculum; and (3) the student begins to attend hospital wards during his pre-clinical studies.’ In providing these caveats and qualifications, WHO officials emphasized reader discretion and the difficulty of determining equivalency across these disparate national systems.
The educational profile of European nations was far more robust than that of their non-European counterparts, and some directory users misconstrued this absence as an indication of lower quality instead of the logistical difficulty of compiling the information. Nevertheless, in 1956, when the ECFMG began its work, this was less of an issue than it would have become by 1965 when the Hart-Celler Immigration Act changed the demographic constitution of the skilled migrant. After 1965, there were at least two to three times more Asian physicians immigrating to the US than European practitioners and information on these people was scant.Footnote 37
Again, the same issue was presenting itself over and over; administering and managing this particular kind of skilled-labour migration proved to be ‘a major headache for those trying to assess the potential competence of those wishing to enter the country’.Footnote 38 In 1970, the National Institutes of Health took an interest in the specifics of the foreign-physician problem and commissioned a study by Yale Medical School researchers Rosemary Stevens and Joan Vermeulen called Foreign Trained Physicians and American Medicine. In their report, Stevens and Vermeulen identify three main areas of concern: labour roles and distribution, accreditation and competence, and the role of the government in immigration. On the issue of licensure, accreditation and competence, the researchers recognized that assigning the ECFMG the task of operating as an obligatory passage point was a necessary and prudent intervention to provide some semblance of quality control. They explain that the ECFMG certificate is a kind of provisional license that allows foreign physicians entry into the profession as interns and residents, but note that the ECFMG examination only ‘tests at a minimal level’. Hopefully, they add, it screens out ‘the patently unsafe practitioner’, but it cannot ‘pretend to certify excellence’.Footnote 39 The complex issue of certifying excellence remained intractable. A multiple-choice examination could only go so far to dispel concerns of quality and competence, and the WHO directory was cursory at best.
Quality and competence were part of a tacit education that evaded standardized testing and regulatory accreditation. This kind of knowledge was supposed to occur through the educational process itself. In 1974, Dr Aaron Lowin of InterStudy – a prominent health policy and research organization founded by Dr Paul Ellwood, the architect of the Health Maintenance Organization (HMO) Act of 1973 – testified before a congressional hearing on health manpower. Lowin presented findings from a study on the challenges of evaluating foreign physicians. The InterStudy report highlighted a fundamental difference between US-trained physicians and their foreign counterparts. It stated,
American medicine prides itself as a quality system. Excellence is introduced in the rigorous training of our medical students and interns, with the result that the fully trained physician leaves the education system possessing both the technical expertise for high quality care and an internalized self-control system for continuously motivating the attainment of these highest standards.Footnote 40
While testing protocols did some work in assessing skill and quality, the ‘roots of high quality care [were] anchored’ in the educational process itself that inculcated a mode of behaviour and comportment.Footnote 41 There was an implicit assumption that this process was particular to American institutions, which were imagined to produce practitioners who were not just better trained, but also more rational, self-controlled and trustworthy.
The authors of the report never identified how this internalized self-control system was taught – except for mentioning that the US trainee was observed in various contexts – and this lack of specificity is telling. Rather than offering concrete evidence, the report relied on cultural stereotypes and unexamined assumptions about the inherent superiority of US medical education. The supposed deficiency of foreign medical graduates was thus attributed to their country of birth rather than to any specific educational shortcoming. The amorphous ‘self-control system’ acted as a powerful barrier that reflected cultural anxieties about foreigners rather than any measurable standard. Even foreign physicians who passed rigorous standardized exams such as the ECFMG and FLEX found their competence and professional ethos continually doubted.Footnote 42 The InterStudy report ultimately described foreign-physician integration as a ‘socio-technical problem’, one that could not be solved by technical solutions alone. Better tools were required for any satisfactory resolution.Footnote 43
But better tools for judging foreign physicians’ competence never arrived. Fundamentally, mainstream medicine remained suspicious of these physicians because of the unknown social conditions that structured their lives before entering the United States.Footnote 44 Nevertheless, foreign physicians from postcolonial Asian nations continued to join the labour force and work in communities neglected by their US-trained counterparts. And US politicians continued to tout the benefits of this migration as a feature of the new economic order that should promote unimpeded movement of prime human capital.Footnote 45
Understanding the migration of foreign doctors as a ‘socio-technical problem’ rather than merely a technical issue reflected broader economic shifts. As neoliberal economic thought gained prominence after the Second World War, the category of labour was reinterpreted. In classical economic theory, the driver of economic activity included land, machinery, physical capital and a homogeneous abstract labour unit. In the post-Second World War era, neoliberal economists reconceptualized labour as a primary driver of economic activity and reanimated the category using the language of human capital. They argued that human capital comprised innate and acquired elements, such as education, professional training and parental involvement. In this new model, individual labourers became what Michel Foucault calls ‘abilities-machines’, people who maximized their skills, behaviours and actions to increase their market value. Crucially, the worker and their skill are inseparable, and one cannot be disaggregated from the other as they were in the classical economic model. This new entangled labour unit now formed the basis of market exchange.Footnote 46
In Foucault’s analysis of neoliberal thought, he identifies mobility, and specifically migration, as an important behavioural input with the potential to increase economic value. Human capital should be able to move, and migration is viewed as an investment by individuals to increase their future earning potential.Footnote 47 However, as seen in the case of foreign-physician migration to the United States, the ideal of free circulation of skilled labour reached a limit when confronted with a xenophobic social world primed to devalue the acquired elements of education and training due to the innate circumstances of country of birth. Indeed, this was a ‘socio-technical problem’ that could only be rectified if the recipient social world acknowledged that skill and competence were not homogeneous (even amongst US medical graduates) and that testing and more testing were covering up the real issue: foreign physicians threatened the normative identity and authority of the medical profession.Footnote 48 Therefore, no matter how many examinations a foreign physician passed, the US medical establishment considered these assessment tools a poor substitute for a social education that included an immeasurable tacit dimension.
The current phase
By the late 1960s and early 1970s, the ECFMG had solidified its role as the primary regulatory body overseeing foreign physicians seeking to practise in the United States. In 1977 it took on full responsibility for visa sponsorship and the verification of educational credentials. However, consensus around how this should be carried out remained elusive. Some regulators argued that by the time a foreign physician passed all the licensing exams and completed their training, the quality of their medical-school education was immaterial, and that this was a distraction.Footnote 49 Others, however, were unwilling to overlook this aspect.
Moreover, the rapid proliferation of medical schools around the world at this time added to the already complex challenges of accreditation and equivalency. The World Health Organization tried to keep up and expanded the World Directory of Medical Schools significantly over the decades, with its seventh edition in the year 2000 listing 1,642 medical schools – an increase of 190 per cent from the 566 schools recorded in its inaugural edition.Footnote 50 But although the list grew in size, the extent of the information that the WHO collected was not enough to quiet suspicions of inadequate training. There was little information about learning objectives, curricular content, teaching methods or evaluation methods, and no sense of how national assessment and accreditation worked in each country.Footnote 51 The scale was too massive for the WHO to tackle alone. It required supranational collaborators to make any progress on this issue.
In 1974, the WHO turned to a newly established non-profit, the World Federation of Medical Education (WFME), to develop a systematic approach to global standards and accreditation in medical education. From the outset, the WFME’s organization reflected the geopolitical hierarchies that structured international health governance. For its first decade, the central office was housed at the Association of American Medical Colleges in Bethesda, Maryland – an unsurprising location, given that the United States was the primary destination for foreign physicians. The office later moved to the United Kingdom, Denmark and Sweden, further consolidating the dominance of the global North in defining the parameters of ‘quality’ medical training. Structured around six regional associations for medical education that mirror the WHO’s own regional divisions, the WFME positioned itself as a facilitator of global collaboration and curricular reform. However, its principal funders – the WHO, UNESCO, the ECFMG and private foundations – reinforced the disproportionate influence of Euro-American institutions in shaping what counted as global standards.Footnote 52
In 1988, at a World Conference on Medical Education, the WFME, along with the WHO, issued the Edinburgh Declaration on Medical Education.Footnote 53 This declaration was a landmark call for reform in medical education and eventually led to the creation of the WFME Global Standards for Quality Improvement in Medical Education in 1998. It had two key objectives: first, to assist with implementation of standards that were proposed by international organizations and experts, and second, to protect and improve the standards of medical education so that ‘internationalization in medicine can continue by supplying national authorities, and potential students, with valid information about the realities of medical education programmes’.Footnote 54 These standards provided a comprehensive framework for improving the quality of medical education at all levels – undergraduate, postgraduate and continuing professional development – and identified consistent benchmarks in medical education to ensure that physicians could be mobile and legible worldwide.Footnote 55
If these standards were met, the WFME, in collaboration with the University of Copenhagen, would include the medical school in its Avicenna Directory. This new database was launched in 2008 to replace and update the WHO’s World Directory of Medical Schools for the digital age. In a Lancet article announcing the project, the architects of the directory explained that they choose Avicenna (or Ibn-Sina) as the namesake because he was ‘noted for his synthesis of knowledge from both east and west’. His name symbolized ‘the worldwide partnership that is needed for the promotion of health services of high quality’.Footnote 56 The authors argued that the information in the directory was necessary to understand where and how health professionals around the world were educated, especially as the number of questionable for-profit institutions was growing rapidly in some countries, and to effectively translate them from the ‘East’ to the ‘West’. In an era of increasing international professional mobility, schools of questionable quality put patients all over the world at risk.Footnote 57
Although the WFME created universal standards and benchmarks, they had no formal implementation or enforcement mechanisms and relied on the information and judgement of local officials to do this work. To address this concern, in 2012 the WFME launched a Recognition Programme that evaluated and recognized accrediting agencies within countries – such as national accrediting bodies or governmental health ministries – and granted them a special recognition status. This status signified that these national bodies were legitimate and could be entrusted to judiciously assess medical schools under their purview and honestly report on whether the schools met the benchmarks.
While the WFME was working on the Avicenna Directory, the ECFMG, along with a partner organization it created called the Foundation for Advancement of International Medical Education and Research (FAIMER), had started assembling its own International Medical Education Directory (IMED) in 2002. Like the Avicenna Directory, this database provided comprehensive information on medical schools worldwide that were accredited by reputable national authorities in their respective countries. This became a key tool for the ECFMG in verifying credentials of foreign physicians and was used by US state licensing boards to grant licensure. In 2014, the Avicenna Directory and the International Medical Education Directory were merged to form a unified, comprehensive resource called the World Directory of Medical Schools. For inclusion in this compendium, medical schools must be accredited by a WFME-recognized agency that vouches for their standards, and the ECFMG will only sponsor the application of a foreign physician who has completed their medical education and training in one of these institutions.
In this elaborate system of global documentation, with layers upon layers of checks and more checks, predictably there emerged insurmountable gaps. Former president and CEO of the ECFMG explained that although medical schools must be recognized by the appropriate authorities, it is very challenging to control the on-the-ground assessors. The WFME Recognition Programme was a first step, and the ECFMG recently adopted a Recognized Accreditation Policy. This policy states that
an accrediting agency of a medical school has itself been reviewed and recognized by an external quality assurance organization. This quality assurance/recognition organization, in turn, has been reviewed and approved by [ECFMG]. Only medical schools accredited by an agency that is recognized by an organization approved by [ECFMG] will satisfy the requirements of the Recognized Accreditation Policy.Footnote 58
The problem was getting too unwieldy, and regulators needed regulating.
One of the unexpected outcomes of this elaborate system was the granting of future accreditation to medical schools in some countries. For example, in September 2023, the National Medical Commission of India – an approved accreditation body – was awarded the ‘coveted WFME recognition status for a remarkable tenure of 10 years’ for their ‘unwavering commitment to the highest standards in medical education and accreditation’.Footnote 59 This recognition meant that the approximately seven hundred existing medical schools in India are now WFME-accredited and included in the official World Directory. Furthermore, any medical schools established in India in the next ten years will also automatically receive this WFME accreditation.Footnote 60 A spokesperson for India’s National Medical Commission was reported as saying, ‘WFME’s recognition underscores that the quality of medical education in India adheres to global standards. This accolade empowers our students with the opportunity to pursue their careers anywhere in the world.’
Put another way, since the National Medical Commission was accredited by the WFME, all Indian medical students are eligible to apply to the ECFMG for entry into the US health care workforce. As of November 2024, the ECFMG declared that applicants who wish to receive ECFMG certification – a prerequisite for working in the United States – must have attended a medical school that was accredited by an approved agency. India’s medical schools are now internationally recognized as meeting high standards for the next decade, which allows graduates to continue to pursue medical careers in countries like the United States. It also ensures the continued flow of Indian physicians, who often fill critical gaps in the US health care system.Footnote 61
Conclusion: inconclusive
In 1910, when Abraham Flexner published his findings about the current state of US medical education and practice, he found it inconsistent, perfunctory and in desperate need of a coherent set of standards. To fix the problem, Flexner recommended higher admissions requirements, basic science and laboratory-based learning, hospital training, and national curricular standards. These recommendations, which quickly operated as mandatory decrees, effectively closed the profession to all but a narrow social demographic.
Over the last sixty years, questions of standards have once again become central to medical education, but this time the dilemma is global in scope. At issue are the foreign physicians and how best to integrate them into American medicine. What benchmarks should determine whether these practitioners are qualified to care for US patients, and who should be responsible for setting, policing and enforcing these norms? Critics from the global South argue that the current system of global medical accreditation does not aim to raise global standards universally and address larger equity issues.Footnote 62 They question whether a single set of standards can ever be flexible and capacious enough to address the world’s diversity. Instead, they contend that the global accreditation system privileges the knowledge and organizational models of the global North, subtly pressuring countries in the global South to replicate these practices – ultimately enabling the global North to absorb practitioners trained at the expense of the global South. Simply put, accreditation is considered a mechanism for the global North to ensure confidence in the cheap labour it imports to care for its most vulnerable populations.
The integration of foreign physicians into US medical practice has been managed through a complex system of regulatory institutions nested within institutions, directories absorbed into other directories, and exhaustive standards and examinations. These processes of standardization, accreditation and validation designed for purposes of quality control reveal a paranoia that permeates the figure of the foreign expert. At its core, it is an exercise in veridiction – can we trust you, Dr Hakim Ahmed? While the answer remains tenuous, the likelihood that the flow of foreign physicians to the United States slows remains unlikely. Currently, the US faces physician shortages that are only projected to worsen in coming years. This is especially pronounced in specialities such as internal medicine, family medicine, pediatrics and psychiatry, and in under-resourced urban and rural communities.Footnote 63 Foreign physicians have been instrumental in filling some of these gaps and will remain critical in the years to come.
Acknowledgements
For their general support and incisive feedback on this piece, I would like to thank Angela Creager, Lara Keuck and the anonymous reviewers. My thanks also to the team at BJHS Themes, especially Jahnavi Phalkey and Trish Hatton, for their help in bringing this article to publication.
Competing interests
The author declares none.
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