What to do with foreign physicians?

The arrival of Venezuelan anesthesiologists to Colombia has raised concerns among their Colombian colleagues, who see this as a threat to their employment status.

I will make a few brief comments regarding the issue of the immigration of professionals around the globe so I can further discuss the particular situation of this phenomenon in Colombia.

Migration between countries is a universal phenomenon. It has multiple causes: political, economic, work-related or social. This is inevitable. It is observed more often from countries with lower resources toward developed countries, but it can also occur among countries with a similar degree of development. There are times in history where migration occurs from country A to country B. In a different moment, the situation may reverse. It is impossible to oppose to it, especially if there are international agreements that facilitate it. What is important, from my perspective, is that the colleagues that migrate from one country to another: (1) Have a proper preparation, so they can guarantee an excellent medical practice for the community; (2) Completely fulfill all the requirements that the State of the recipient country demands of foreigners entering the country and (3) Do not represent a threat to national professionals.

The Department of Epidemiology of the University of Pittsburgh School of Public Health published an article in 2005 about the brain drain of healthcare professionals.¹ They propose that professionals from developing countries are attracted to developed countries because of better living conditions, but also because their services are required there. A significant proportion of them have specialized in the country that receives them. This is to the detriment of the poorest countries that have invested large resources in their undergraduate studies. The authors of the article explain that this migration damages their health systems. They conclude that improving working conditions for workers that could be attracted to migrate should be sought in developing countries. Also, professionals that arrive to developed countries could be used to bring the knowledge and technology they have acquired in first world countries to their home countries.

Besides the motivations for the migration of professionals, there is an aspect related to their training. Cuba is one of the countries that produces more physicians and other healthcare professionals than it needs,² like other countries including Egypt, the Philippines and India. At the other end of the spectrum are countries like United States and Canada, which are training a relatively low number of professionals considering their requirements.

The WHO (World Health Organization) has analyzed the issue of physician migrations. They have proposed some policies such as: (a) Linking international migration with the goals of healthcare policies in the countries involved; (b) Identifying the countries for which migration implies less harm; (c) Regulating international movements of health workers in a way that allows the home countries to train the professionals required in other countries without affecting their own healthcare system; (d) Protecting the rights of the professionals of the receiving country and (e) Establishing appropriate guidelines for bilateral compensation agreements between the home countries and the ones that are receiving professionals.² Clearly, despite the good intentions of such recommendations, they are not easy to implement.

The damage suffered by developing countries from which professionals are migrating should also be noted. The lack of professionals has had devastating effects in developing countries, such as those in sub-Saharan Africa and the Caribbean. Causes for this “brain drain” are varied ranging from working conditions in home countries to the need of the richest countries for qualified human talent. Jamaica is mentioned as one of the hardest hit nations by this phenomenon. Lofters argues that solutions for this problem have been sought; however, it requires a real commitment and cooperation form all nations, including financial support.³

Now we will observe the migration situation of physicians and healthcare professionals trained abroad who are entering Colombia.

On July 27th, 2016 a Forum on Human Talent in Healthcare was held at the Universidad Nacional de Colombia. This event focused essentially in the validation of titles of healthcare professionals trained abroad. The issue of migration in Colombia and the world was also discussed. It was reported that, according to the census of population conducted by the Colombian National Statistics Department (DANE) in 2005, 3,331,107 Colombians lived abroad, 35.4% of them in the United States, 23.4% in Spain and 18.5% in Venezuela. That year, about 500,000 people were living in this last country.⁴ In 2014, the movements of Colombians to other countries were superior to the movements of foreigners to Colombia. It is necessary to research the data corresponding specifically to professionals of the healthcare area.

During the forum, some of the anesthesiologists that attended the event talked about some situations they are experiencing in their regions, such as Guajira, Norte de Santander and even the capital city of the country. Two irregular phenomena are occurring in regards to the migration of colleagues trained abroad: some colleagues have submitted their papers and their degrees have been validated (not always in due form), while others are definitely practicing the profession illegally, without fulfilling the requirements demanded by our legal system.

It was also reported that some institutions are hiring foreign specialists to the detriment of Colombians, with lower wages than those that already exist.

What to do about this situation?

The physician, national or foreign, who has received his professional training outside our country, must go through a series of formalities to reside inside the country and practice a specialty:

The physician must apply for their visa before the Ministry of Foreign Affairs and must process their foreigner's identification card (cédula de extranjería) before Migración Colombia.

They must fulfill the requirements to validate the title of physician or specialist before the Ministry of Education.

They should take their apostilled documents, including the completion of the Compulsory Social Service, before the Secretariat of Departmental Health or the Special District, if located in Bogotá.

Finally, the professional must submit their documentation in order to be admitted to the Colombian Medical College.

The Substantive Labor Code of the Republic of Colombia, article 74, requires that every employer with more than 10 employees was obliged to hire Colombians in a proportion of not less than 90% of the unqualified personnel, and not less than 80% of qualified staff. This article was deleted by the legislator.

The Ministry of Education, through Resolution 6950 of May 2015,⁵ has regulated the procedure and the requirements for the validation of degrees awarded by institutions of higher education or institutions legally recognized abroad. According to the resolution, the aim is “to ensure the academic suitability of those who obtained academic degrees abroad”.

Unfortunately, the Ministry of Education has been limited to examining some papers, which is not always a guarantee of good training.

Despite the concern generated by the migration of specialists and health professionals, several actions could be taken to limit their negative impact:

As a first step, it is necessary to verify that all professionals entering the country comply with the aforementioned requirements in the Ministry of Foreign Affairs, as well as in the Ministry of Education and in the corresponding Department of Health. If it is clear that these minimum requirements are not met, the corresponding complaint must be filed with the competent authorities. For example, if it is known that a colleague does not comply with what is stipulated by law, the fact must be reported to the appropriate Department of Health. If this entity does not take action against this infraction, the fact can be reported before the Attorney General of the Nation, due to the negligence of the corresponding officials.

On the other hand, it is evident that the Ministry of Education is not carrying out its task of “assuring the academic suitability” of those who enter. It is at this point that I believe scientific societies must offer their competence so that such suitability can be ratified. A mechanism should be sought by which the scientific societies take an active and effective role in the evaluation of physicians who intend to practice their profession in the country. The university or institution of higher education that trained the colleague who enters the country must be recognized by Colombian professors with the appropriate academic authority. In addition, the professional who enters should be evaluated. It is said that more cannot be asked of professionals entering the country than of those who have been trained in the country. For this reason, the recertification of professionals already in Colombia must be established, and those entering the country should also be subject to such certification.

The Compulsory Social Service is another topic to consider. The resolution mentions that this is one of the requirements that must be filled by whoever enters. It must be ensured that this requirement is also met, because this is not always the case. Otherwise, the professional must fulfill it in some way in the country.

One of the ways to protect the nationals, could be to find way to ensure that those who come from abroad must practice in those territories far from the large cities, in rural sectors.

Finally, I believe we should change our attitude toward immigrants. If these colleagues come to establish themselves in our country to offer their services to the community, fulfilling all the requirements that we have discussed, in such a way that they can practice with absolute suitability and within the law, we must welcome them into our medical profession. We will have to imbue them with our goals and our struggles. If this is so, they will surely come to strengthen the profession. Some of them may even contribute scientifically and professionally and the perception of unfair competition could definitely be eliminated from our environment.

I am very convinced that the Board of Directors of the Colombian Society of Anesthesia and Reanimation (S.C.A.R.E.), with Dr. Ricardo Navarro and the organization's top management, will find a way to make the national government listen carefully to the contributions that can be made as a scientific society and medical profession so that we can all be strengthened by this situation arising with the arrival of colleagues from abroad. I know that the Academic Subdivision has advanced a very serious study on the contents of a training program in the postgraduate studies of anesthesiology, which can be taken as a reference by the Ministries of Education and Health when comparing the skills and suitability of the professionals who wish to enter the country. There is an abnormality in this aspect, since in other countries the Ministry in charge of this task is the Ministry of Health. After all, the professional will exercise within health guidelines. In our country, this responsibility lies with the Ministry of Education, which is not the most appropriate body to evaluate the competencies of the anesthesiologist or any specialist. As such, there has been an apparent flexibility in these procedures.

In Colombia, 2016 was declared by scientific societies as THE YEAR OF HUMAN TALENT IN HEALTH, during which the Colombian Society of Anesthesiology and Resuscitation (S.C.A.R.E.) has seen fundamental participation and leadership. We already mentioned the Forum on the validation of foreign titles. Another will come on exclusively labor issues. These events, in which scientific societies as well as ministers and officials of the national government participate, will certainly help to establish suitable outlets to face the problems we are dealing with, as well as many others that concern the profession. There are many expectations we have about the outcome of these forums.

Financing

The author was not sponsored to carry out this article.

Conflicts of interest

The author has no conflicts of interest to declare.