Editor’s note: This is the second part of a series examining the hurdles immigrants and refugees with professional credentials face in Washington state.

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Athanasios Siopis knows how to make a latte. He also knows how to diagnose pneumonia and treat a heart attack.

Siopis is among hundreds of doctors trained outside the U.S. and now living in Washington, but are stuck in the lurch. They have the skills and often years of experience treating patients in their home countries. But when they arrive in the U.S., they find the process of getting credentials to practice is expensive, time consuming and difficult.

Siopis is a permanent resident and has more than a dozen years of experience on top of his medical school training, which he received in Greece. He left Greece and came to the U.S. in 2016 in the midst of the country’s economic crisis and austerity.

In Greece, he practiced as a resident family doctor and general practitioner, serving rural populations and working as a sports medicine doctor. He speaks five languages — including English, which he’s been speaking since he was 6 — and is studying even more.

But instead of continuing his medical career in the U.S., Siopis currently works as a barista at a Starbucks in the Puget Sound region.

As reported in the previous installment of this series, many immigrant and refugee professionals face challenges gaining credentials to work in their field in the state. Doctors and physicians trained abroad — with all the specialized learning required — face their own challenges and are known as international medical graduates (IMGs).

Despite his experience, and like so many other IMG doctors in Washington state, Siopis is stuck at square one. To get licensed in the U.S., among the tests he would have to pass is a three-part medical test administered by the Educational Commission for Foreign Medical Graduates. Each portion costs about $1,000. After that, he would need to land a residency position at a teaching hospital for a minimum of two years, and there’s no guarantee he would get one.

“You have the abilities. Like I’ve been examining more than 150 kids per day in an emergency room as a family doctor,” said Siopis, a West Seattle resident, of his medical practice in Greece.

But for now, he’s taking orders and blending coffee — and his medical skills are idling even as the state needs more doctors. He’d like to practice medicine again, but the prospect of spending thousands of dollars on tests with no assurance of landing a residency or being able to practice has kept him from starting the process.

“I would very gladly go out there and work as a rural doctor today,” he said.

Left out of residencies

For doctors who complete their tests, there are still barriers. Ahmed Saleh has been waiting for years to land a residency in a U.S. hospital, which would let him become a fully-licensed doctor. He’s already passed all of his medical exams.

He’s been applying for residencies in Washington state for years, but hasn’t been able to land one, he said. Residencies are the final piece of training for aspiring doctors because it lets them get years of hands-on experience before they receive their license. But there’s a shortage of spots, and fierce competition for those that exist.

“I’m struggling to get into residency, and Washington state is one of the places that is not international medical graduate friendly when it comes to residency,” Saleh said.

Saleh graduated from Al-Azhar University in Cairo and immigrated to the U.S. about five years ago to finish his medical training.

He decided to look outside of Washington recently. Saleh participated in an observation rotation in Cleveland where he watched doctors work. He also interviewed for the hospital’s clinical rotation program, a months-long training session where students get hands-on experience. These rotations are generally a prerequisite for full residency spots.

U.S.-trained doctors undergo clinical observations as part of their final year of school, and graduates of domestic schools enter into a limited number of residencies available each year. If aspiring doctors don’t land a residency within a few years of their clinical observations, they may be required to do them again.

“It’s hard to fulfill that request,” Saleh said. “And also the other community programs in Washington state, they have few spots, and they would rather take people from like University of Washington, or have graduated in a certain amount of years.”

Residencies are largely allocated through an organization called the National Resident Matching Program, through a process called the Match. It takes hospital requests for residents and finds candidates to send them.

According to its 2019 report, there were than 38,376 residency applicants across the country and 35,185 positions. Of those matched, nearly 19,000 were U.S. medical school seniors. Roughly 94 percent of domestic students were offered a residency position.

For IMGs, the percentage of matches drops significantly to about 59 percent in 2019. Since 1982, the earliest year data was available from the Match report, IMG residency candidates have never been matched more than 60 percent of the time.

Dr. Mohamed Khalif saw these challenges, and began advocating for immigrant and refugee doctors in the state. Khalif was born in Somalia, and worked with the Somali Health Board to introduce state bills to address the issue of IMG doctors missing out on residency positions. Khalif is in the process of getting licensed too, and said he’s passed all three medical tests.

Mohamed Khalif is the founder of the Washington Academy for International Medical Graduates. He’s pushing for changes to state law which would help more internationally-trained doctors land residencies needed to get accredited in the state. Aaron Kunkler/staff photo

Khalif said there’s little transparency on how the Match places residency applicants, even though most positions are partially funded through Medicare. He’d like to see more information on its internal workings.

“It’s kind of like the NFL draft,” he said. “They’re drafting a lot of kids from college, but you don’t know who they’re considering.”

Khalif, who lives in SeaTac, started the Washington Academy for International Medical Graduates (WAIMG) last spring, which studies barriers for immigrant and refugee doctors. It stemmed from SB 5846, which was sponsored by Sen. Rebecca Saldaña (D-District 37). The bill also created an IMG work group to make recommendations to the Washington Medical Commission. A report was submitted to lawmakers last December.

Pushing for change

On an overcast Saturday afternoon, Khalif stood outside the doors of a humble strip mall in east Bellevue. He welcomed people, shook hands with those arriving and directed them toward the doors. Inside, aluminum platters filled with food from countries ranging from Ethiopia to Venezuela to Ukraine topped tables.

In the next room over, rows of chairs were filled as people trickled in for WAIMGs first fundraising event — an international food tasting. Khalif took the microphone and gave a short presentation.

The WAIMG represents some 150 physicians from 30 countries. Many of the doctors Khalif works with have already completed costly exams and certification through the Educational Commission for Foreign Medical Graduates. The last piece that many of them are waiting on is their residencies.

“The problem is, once you finish those exams, your degree means nothing if you can’t finish residency,” Khalif said.

In the meantime, roughly 60 percent of them are either working in warehouses, driving for Uber or unemployed. Khalif said he knows of roughly 400 IMG doctors in Washington state.

The federal government funds residency positions. In 2015, state and federal agencies spent more than $16 billion in training. That same year, Washington hospitals received $11 million of those funds. The federal portion of this funding comes from Medicare Graduate Medical Education (GME) program. But after the Balanced Budget Act of 1997 passed, funding was frozen.

For the first few years, positions and residency applicants kept pace. But by 2003, the number of applicants began to outpace Match positions and federal funding.

Federal spending covers roughly 20 percent of the costs to train a resident, said Janis Orlowski, the chief health care officer for the Association of American Medical Colleges (AAMC). It’s also short of what’s needed.

“Almost 23 years now and it hasn’t been re-evaluated,” Orlowski said.

Some universities have created positions even without federal funding, she said. But this hasn’t kept pace with demand. According to the AAMC, there were 1,201 residency positions in Washington state. Some 302 of these positions were not supported by federal GME funding.

Washington state has fewer positions available than several other states. For example, Michigan has around 6,200 resident positions, Missouri has 2,200 positions and Minnesota has 1,503, to name a few.

The AAMC supports federal legislation that would increase the number of slots the federal government funds by 15,000 over five years. Both the Senate and House bills have been stuck in committee since early 2019.

International medical graduates could help care for Washington’s aging population. The state’s Office of Financial Management said there was more than 1.17 million people in Washington that were 65 or older, accounting for 16 percent of the population, according to a 2018 report. By 2040, this is projected to increase to more than 2 million, accounting for 22 percent.

A 2016 University of Washington study found that in rural areas of Washington state, more than half of physicians are 55 or older. As they retire, IMG doctors could help fill the gaps, Khalif said. They can also provide culturally competent care for immigrant and refugee populations in the state.

Khalif gave an example of one patient who was diagnosed with diabetes and was prescribed expensive medications. Due to a language barrier, they didn’t know they could ask for cheaper or generic medicine, and as a result became temporarily homeless due to the cost. Khalif said clinical medical knowledge is important, but building relationships with patients is just as important.

“All of these things contribute to their health,” he said.

Olympia could act

With Congress in gridlock, Washington state legislators are beginning to take action in Olympia.

In the 2019 state Legislative session, Sen. Rebecca Saldaña sponsored SB 5846, which created an IMG work group. It was tasked with researching barriers for foreign-educated professionals, and recommending ways to address them.

That group, which included Khalif and other stakeholders, submitted their report last December. Several of these recommendations were included in a bill filed this session by Saldaña and Sen. Derek Stanford (D-District 1), among others. SB 6551 would do several things, like adopt an assessment program to determine readiness of IMGs to apply and serve in residency programs. It would also provide funding to organizations that support IMGs, such as Highline College’s Welcome Back Center.

Stanford said he became aware of the issues surrounding IMG doctors after his constituents raised concerns with him. In future sessions, he’s hoping to get the state to kick in more funding for residency positions for all doctors in training, on top of passing SB 6551 this session.

“It’s an issue for everyone in the system, and it’s an issue in the state, trying to have a workforce going forward that’s appropriate to our needs,” he said. “But it especially impacts the international medical graduates who come here and who are fully qualified and ready to go into a residency, but don’t have that opportunity.”

Doctors with substantial bodies of published work and for whom other accredited doctors vouch for could receive licenses more easily.

Further, it would allow the Washington Medical Commission to issue two limited licenses for public work. They would allow IMG doctors to work for certain state, city and county agencies if they are licensed to practice medicine in another U.S. state or Canada. A third license would allow doctors who have completed all steps except a two-year residency to be able to practice as a resident under a physician instead of through a hospital.

“I’m just really excited about the opportunity to remove some barriers for some talented folks who want to contribute to our state,” Stanford said.

And that’s exactly what Siopis, the Greek family doctor, said he wants to do.

“What I want to say in huge letters is we’re here to help,” Siopis said. “Please accept our help.”