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The following is a transcript of the podcast episode:

Rachael Robertson: Hey everybody, welcome to MedPod Today, the podcast series where 乌鸦传媒 reporters share deeper insights into the week's biggest healthcare stories. I'm your host, Rachael Robertson.

Today, we're talking with Kristina Fiore about international medical graduates and residency. Plus, Sophie Putka tells us about a Miami doctor facing complaints related to a Brazilian butt lift gone wrong. Then, I'm going to share some of my reporting on new research on gender and sexual harassment during internship, as well as the documented problem of the gender pay gap in medicine. Stick with us, but first, onto our first segment.

Last year, Tennessee became the first state in the U.S. to scrap residency requirements for certain international medical graduates, or IMGs. Since then, more states have passed laws that offer a permanent alternative path for licensure for IMGs. In fact, 15 states now have passed or are considering such legislation. And Kristina Fiore is here to tell us more.

Kristina, which states have passed these laws that cut residency requirements for some IMGs?

Kristina Fiore: Yeah, so two states so far, Tennessee and Illinois, have passed laws that allow some IMGs to bypass residency and get a 2-year provisional license. After that, they can apply for a full license, and they'll be able to practice medicine all on their own. Now, I say some IMGs because both laws stipulate that candidates have to be legally entitled to work in the U.S. -- so basically, they have to obtain their own visa.

There are also other requirements that differ by each state. Tennessee requires the IMG to work in an academic medical center with a residency program for those 2 years, and Illinois requires that IMGs work in underserved areas during that time. But overall, IMGs are pretty happy about the changes. That's according to a few sources who I spoke with.

There are two other states that offer provisional licenses for a set period of time, and those are Florida and Virginia. Both of those laws have been passed by the state House and the Senate, but they're currently awaiting their respective governor's signature.

Robertson: So you also mentioned in your article that other states have passed different laws that make it easier for IMGs to get their U.S. licenses. Can you tell us about those?

Fiore: Yeah, so there's also Alabama and Colorado, and both of those cut down the length of residency. So IMGs can essentially apply for a license after 1 or 2 years of residency instead of after 3 years. Idaho and Washington have allowed IMGs to obtain temporary licenses. But those expire after about 2 years. There are seven other states that have introduced legislation and that legislation runs the gamut of all these pathways I've mentioned, but we still have to see if any of those pass.

I also just want to note that there was some controversy around this. So in Tennessee, for instance, the general counsel for the Tennessee Medical Association told me that its members raised concerns about losing their jobs, because hospitals would save a lot of money by employing IMGs. There's also concern about ensuring a national standard of quality when these state laws vary so much. And recently, an alphabet soup of medical education regulation groups -- the ECFMG, the ACGME, and the FSMB -- they're going to be meeting in April to talk about how they can make a more standardized approach given the rising tide of all this legislation.

Robertson: And speaking of controversy, you wrote a different story about how IMGs are being offered pay-to-play residency positions. What is going on there?

Fiore: Yeah, so during Match week, some IMGs posted on Reddit channels that they were approached by a company claiming it had us residency positions to offer -- for a price. That price? $150,000 to $200,000. Now that sounds extreme and completely unbelievable, but sources told me that some IMGs from wealthy families do have the means to pay those prices. And indeed, we came across a court case from 2018, where the parents of a hopeful resident paid $400,000 for their son to take a position at a hospital in Michigan. And when that resident was later dismissed from the program, the parents wanted their money back. But the hospital argued that since the money was technically a donation, they didn't have to refund them. And ultimately, a jury sided with the resident and his family and awarded them $480,000. So yeah, clearly there is precedent for someone to pay their way into one of these very pricey residencies.

Robertson: That is truly wild. Thank you so much, Kristina.

Fiore: Thanks, Rachael.

Robertson: Now we'll head to Miami which has been a hotspot in recent years for deaths and injuries related to gluteal fat grafting, also known as the Brazilian butt lift, or BBL. In May of last year, state lawmakers passed a bill with some measures designed to make the procedure safer. But the state is still fielding complaints about the poor care patients received in the lead-up to the new law. Sophie Putka will tell us more.

Sophie, can you tell me a little bit about the latest complaint related to BBLs in South Florida?

Sophie Putka: Sure. So in 2021, Julio Clavijo-Alvarez, MD, saw a woman for a BBL at a clinic called New Life Plastic Surgery. And in a recent complaint filed against this doctor -- it's his third in 2 years -- the Department of Health alleges he placed what's called the JP drain improperly during the procedure. It was too deep under the abdominal muscles and inside the abdominal cavity. So the patient experienced back and abdominal pain and checked into a hospital where she was actually transferred to another hospital and the drain was removed. The Department of Health alleges that the doctor met with his patient after the hospitalizations but didn't actually document all of the complications. They wrote in the complaint that he "fell below the minimum standard of care in his treatment" of the patient and could have his license revoked, suspended, or restricted in some other way.

Robertson: Okay, so in a BBL that's done correctly, where does the drain come in?

Putka: So in a BBL, the fat is removed from the patient's midsection with liposuction and then reinjected into the butt in the layer of fat under the skin, but above the muscle. So I spoke with Dr. Pat Pazmino, an expert plastic surgeon also based in Miami, and he told me water and epinephrine are also injected into this space during the liposuction to limit bleeding and create more working space for the physician, and then the drain is placed there so excess water can come out. Pazmino told me a drain placed the way this one was, though, would be inappropriately deep. It sounded very unusual to him.

Robertson: Got it. And what's the bigger picture here when it comes to the safety of BBLs in Florida?

Putka: Yeah, so BBLs are extremely risky for a cosmetic procedure. And for a long time clinics and doctors with questionable practices were allowed to operate without a lot of oversight in South Florida. There were, and still are, clinics in the area that do many aesthetic procedures in a day. They do so at a very low cost to the patient. And experts have told me that these clinics would often employ contract physicians without comprehensive enough training in these procedures who might rotate in and out of the clinics. So sometimes tasks were even being delegated to staff outside their scope of practice, which is what happened in one of the other complaints against Clavijo-Alvarez. And clinics where patients were injured or even died would simply rename themselves and continue doing business. But there was this new law that passed recently, and the Board of Medicine pointed this out in an email to us, new clinics need an inspection before being registered in Florida, doctors need to meet patients in person at least a day before their scheduled procedure, and surgeons can't perform BBLs on more than one patient at a time. They have to use ultrasound when fat grafting and they can't delegate the liposuction to unqualified staff. So we may be seeing some positive changes coming up in the future.

Robertson: We can certainly hope so. Thank you so much, Sophie.

So now, Sophie is actually going to take the host seat for this last segment.

Putka: Thanks, Rachael. So it's Women's History Month, but we're still a long way from gender equity in medicine. Rachael's here to tell us more about some new research on harassment during internship in the years since #MeToo, and some of her reporting on how the gender pay gap in medicine persists, even though there are more women in the physician workforce than ever before.

So Rachael, one of your recent stories was about a cohort study of trainees. The study assessed experiences of sexual and gender harassment during intern year. What did that research uncover?

Robertson: So in the past 5 years, the rates of both sexual harassment and gender harassment during internship has decreased, so that's good news. And more people recognize it when it's happening. Women and surgical interns had particular growth in recognizing this behavior, but alarmingly, rates of sexual coercion more than doubled for women and for non-surgical interns during their intern year.

Elena Frank, PhD, of the Michigan Neuroscience Institute at the University of Michigan, who led the research team, told me that their team is working on this ongoing study using internship as a longitudinal model of stress. And she told me that this team was in a unique position to look into harassment because they were already collecting data -- so they tacked on a questionnaire about harassment onto this ongoing study. Frank told me that "women may have some unique stressors that they experience under an internship, throughout training, and their careers that can be detrimental to their well-being." And this study was partially inspired by the #MeToo movement and then the ensuing #MedToo movement.

Putka: Wow. So you wrote a different piece recently about another issue facing women in medicine: the gender pay gap. We already knew that since 2017, women make up more than half of medical students, but your reporting shows how it doesn't correlate with full equality in medicine.

Robertson: Yeah, exactly. Women are a growing percentage of the physician workforce, but a strong body of evidence shows that women physicians are paid less than their male counterparts. At the same time, the gender pay gap has decreased slightly from about 28% to 26%, according to Doximity's 2023 physician compensation report.

Vineet Arora, MD, of the University of Chicago School of Medicine, told me that, despite many studies documenting the gender pay gap, the gap has remained consistent. And she pointed out that it's important to think about the pay gap in terms of lifetime earnings and therefore generational wealth, too. Arora worked on a study that was published back in 2021 that found that women physicians make about $2 million less than their male counterparts across a 40-year career. And various other studies and surveys have shown that women make about $100,000 less on an annual basis, and that some of this difference comes down to supplemental income, like research or additional care pay, rather than the base salary itself.

Putka: Got it. So what are some of the contributing factors to the pay gap?

Robertson: So I also spoke with Shikha Jain, MD, who is a physician at the University of Illinois Cancer Center in Chicago, and she founded the nonprofit Women in Medicine. She identified a few major reasons for the gender pay gap. One, women physicians are often offered less starting pay, which makes it harder to negotiate to get to the same level of compensation as their peers. Plus, less money goes towards funding women physicians and researchers. Women are also more represented and lower paying specialties, like pediatrics, and less represented in highly compensated specialties, like surgery. Also, women spend more time doing unpaid labor on committees.

And a huge, huge thing is also family building. Women are more likely to be primary caregivers to children or elderly relatives, which may have also increased during the height of the pandemic. That might mean reducing work hours or being passed up for opportunities. Jain told me that after she had a baby, one of her colleagues told her that she didn't suggest Jain for an opportunity because of that. Jain said that even if it's not with ill intent, "people can assume that you're not interested in responsibilities because you have children."

The pay gap is not an easy problem to solve. But some research has suggested that transparency and monitoring on gender pay gaps, plus policy and work culture changes, and making higher title jobs that get paid more, more accessible to women -- those are just some places to start though.

Putka: Interesting. Okay, great. Thanks, Rachael.

Robertson: Thank you, Sophie.

And that's it for today. If you liked what you heard, please leave us a review -- on or or wherever you listen to podcasts -- and hit subscribe if you haven't already. See you again soon.

This episode was hosted and produced by me Rachael Robertson with sound engineering by Greg Laub. Our guests for 乌鸦传媒 reporters Kristina Fiore, Sophie Putka, and Rachael Robertson. Links to their stories are in the show notes.

MedPod Today is a production of 乌鸦传媒. For more information about the show, check out medpagetoday.com/podcasts.

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