By Cheryl Clark

Members of the Tennessee Board of Medical Examiners felt they were locked in an impossibly tough spot.

They had to choose between defying a new state law -- one their legal counsel sternly advised them to enforce lest they face costly lawsuits -- or approving a licensing pathway for international medical graduates (IMGs) who had never practiced or trained in the U.S.

"What we have to have, legally, to comply with our General Assembly, is a way for these people to come submit their application," chief deputy general counsel David Silvius told members during its July 30 board meeting. And if the board refuses to make that process available, "if (an applicant) decides they want to sue you, that's what they'll do. ... The law says these people are entitled to come ask for a license," he said.

But several board members expressed horror with their options. They said the new statute gives them little to no way to assess applicants' competence, as they have when physicians are trained in the U.S.

During a nearly 90-minute debate, some board members said that if they allowed foreign-trained doctors to get in the door with so few qualifications, they'd be allowing potentially incompetent physicians to harm patients.

"I am now in a medical ethical dilemma as to whether my hands are tied to give people who may not be qualified a license to practice ... to do something that is not in the safety, healthcare, best interests of my citizens," board member John J. McGraw, MD, an orthopedic surgeon, told Silvius. "And if I do, then I may need to resign."

"This is a novel license ... and we're the first (state) to do it," said board president Melanie Blake, MD, an internist. "You're asking us to basically abandon the ethical oath that we took to be here."

Blake added her concern that the statute, called Chapter 211, required these foreign applicants to check boxes, with limited mechanism for the board to verify what they claim.

"I'm a little worried also about a criminal background check when someone's been living abroad for years, and then they come here and we run a check, and it looks perfect," Blake said. "But we don't know what they were doing in Iceland, or Sweden, when they were, you know, practicing euthanasia or whatever, you know, I don't know what we can know about them."

And, she said, "you don't have to pass a single exam to get this license."

To Silvius' warning of liability if the new law was not observed, board member Todd Tillmanns, MD, an ob/gyn, shot back: "We're opening ourselves to liability if we think someone is coming here to practice medicine or otherwise and is not someone that is safe or is practicing in a way that could endanger people."

Applicants may say that, "because you lived in another country with 3 years of practice, and we have no documentation of it, that's legitimate? 'Come on in and practice medicine in the state of Tennessee.' This is what we're so upset about. And it's not because we're standing on high. It's because we're protecting people," Tillmanns said. "There's a reason it takes so long."

Ignoring the Law

After much back and forth, the board voted not to create an application form for IMGs to use, and defied their legislative mandate. It approved posting an explanation of its policy on its website with an FAQ, which simply says, "At this time, the Board does not have an application."

That has left at least 60 IMGs who heard about the new law and wanted to move their practices to Tennessee twisting in the wind, said job agent Stephan Cloutier, who helps link physicians with employers throughout the country.

He said most of 60 clients are from India, "among the best physicians in the world. They are really, really, qualified candidates," who all have Educational Commission for Foreign Medical Graduates (ECFMG) certification, which is now part of Inthealth.

If it were enforced, the current law, which took effect July 1, would require the IMG to show an offer of employment from a setting with a post-graduate training program accredited by the Accreditation Council for Graduate Medical Education.

The applicant also must meet one of these requirements, a key word being "or":

- Demonstrated competency as determined by the Tennessee board

- Completed a 3-year post-graduate training program in the graduate's licensing country, or

- Has otherwise practiced as a medical professional performing the duties of a physician for at least 3 of the last 5 years outside the U.S.

New Law Will Supersede Old One

Yarnell Beatty, senior vice president and general counsel for the Tennessee Medical Association, said his group was vehemently opposed to Chapter 211, "so much so that we lobbied heavily to get the law changed" -- and they succeeded.

Chapter 929 passed, but does not take effect until January 1, 2025.

In addition to changing the name of the license from "temporary license of limited duration" to "foreign training license," the new statute replaces the word "or" with the word "and," so IMGs have to qualify for each requirement.

Until then, the more lenient legislation remains in effect.

"We don't know where they come from. We don't know if they're, you know, from war-torn countries or third-world countries where training isn't, you know, up to the standards of the United States. We just don't know," Beatty said.

"There's got to be some way that you can measure minimum competency," he added.

Authors of the Senate and House versions of the original legislation, Sen. Kerry Roberts and Rep. Sabi 'Doc' Kumar, a retired surgeon, did not respond to repeated requests for comment on the reasons they sponsored the legislation.

One reason might be Tennessee's shortage of physicians, especially in primary care.

According to federal data, Tennessee ranked 44th in the nation for overall health in 2019, and in 2020, nearly all of its counties (90 of 95) were federally designated primary care health professional shortage areas, a problem that has gotten worse. Federal data show widespread shortages of mental health and dental providers as well throughout the state.

One disappointed physician who was eager to practice in rural Tennessee is Bryant Morrison, MD, a U.S. citizen licensed to practice in Baja California in Mexico. He graduated from Universidad Autónoma de Guadalajara School of Medicine in June 2002 and completed an internship at the Hospital General de Zapopan in Jalisco, Mexico the following year.

His Mexicali clinic has a contract to treat employees of Imperial County, California, who travel across the border for their care.

"It was incredulous that the board voted against providing an online application form even after being legally advised to do so by their own general counsel," said Morrison.

In foreign countries, he continued, general practitioners usually only complete a 1-year rotating internship prior to getting licensed and going to work, "similar to what many osteopathic physicians currently do in many rural communities in the United States."

Now, he said, foreign licensed physicians like himself must have completed a residency of at least 3 years in addition to 3 years of practice experience. That, he said, "will preclude general practitioners such as myself who have only completed a 1-year internship from participating and obtaining provisional licensure."

This requirement "will most likely limit the applicant pool resulting in very few foreign physicians coming to the state," he said.

Many foreign-educated physicians said they, too, were excited about a chance to practice in Tennessee, and now feel left in limbo. Most declined to allow their names or circumstances to be published out of concern it could endanger their job prospects.