Meidas Health: Dr. Nick Mark on H-1B Visas and The Future of American Medicine

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Midas Mighty. Hello, welcome to another episode of Midas Health.
This is an emergency pod.

We're going to be talking about all the changes that are happening here with Tylenol and autism, H1B visa increases, potentially for doctors, lots to discuss.

As we mentioned on our last emergency pod on Friday with Ben, this is just, you know, there's no words to describe it, completely unusual, unprecedented times.

So we're doing more and more emergency pods to keep up versus trying to schedule something once a week, which was our former format. We'll keep doing that.

But really, the through line here is bringing you the nation's very best healthcare leaders, clinicians.

thinkers, because we know that those people do not exist at the top of the federal government anymore.

That's why we have created MIDAS Health to bring those people directly to you through this mechanism. I'm really excited to have Dr.
Nick Mark here today for our emergency pod.

And we're going to be talking about the vis-a-vis increases, how it may potentially impact medicine

and other topics. Dr.
Nick Mark is a dear friend of mine.

Him and I actually got to know each other about 15 years ago as interns here in Seattle, Washington at the University of Washington's internal medicine residency program. He is by far and away

one of the smartest, just best clinicians, diagnosticians I have ever met, if not the best.

And he's built quite the name for himself as, in my personal opinion, the nation's very best modern physician when it comes to teaching his peers, like me, what we need to know when it comes to new innovations in medicine, new guidelines to better care for our patients in the ICU.

There is quite literally nobody better, nobody more savvy. He's having a lot of impact.
I'm so proud that he's here with us.

Lastly, I'm going to let him do this because he's going to do this better than I will, but he has an incredible medical education-focused podcast called Critical Care Time.

He does a lot like the one-pager ICU. Again, I'll let him talk about it, but he's having a lot of impact.
And again, that's what we're trying to do here.

We're trying to continue to have scale the impact and bring people that are doing great things in healthcare directly to you. So, without further ado, Dr.
Nick Mark, welcome to Midas Health.

Thank you for having me. Good to see you, buddy.
Thank you for that very kind introduction.

I did

not like when you said 15 years, though. Maybe you could have your people edit that out.

I wish.

Nick, we're having this conversation on the heels of what was

a tweet that went viral that no surprise came from you because you have a way of decomplexifying all things in medicine, including policy in ways that people can understand, which I really appreciate.

But talk to us about that tweet and specifically how it was related to some of these H-1B visa increases. Give us a sense of what we're talking about and why we're talking about it.

Yeah, great question. So, let me just back up and give a little bit of context because I know not all of your audience are like us physicians.

So, we should talk about kind of how the medical training pipeline works. So,

each year, about 28,000 MDs and DOs graduate from medical school in the United States.

The next year, they begin residency. Residency is this process where you are a physician and you are in training, you're taking care of patients, and you're also learning about a specialty.

The problem is there are 38,000 residency spots. So there's 10,000 more residency spots than there are U.S.
medical school grads. So where does that 10,000 difference come from?

Well, it comes from international medical graduates, people who trained just like we did, but outside the United States.

This is an essential part of the physician workforce in the United States.

They come here, you know, some of them are U.S. citizens who trained abroad, and some of them are not U.S.
citizens who come here on a visa. And we rely on

these physicians and the work that they do in order to make the U.S. medical system function.
I should also say that they

predominantly go into more primary care specialties.

So, you know, especially like if you're looking at family medicine and pediatrics, and especially in rural and underserved areas, we really depend upon this pool of foreign-trained physicians in order to care for people in the United States.

Do you suspect, you know, there's been a lot, you put a tweet out there. I encourage everybody to look at it

and to follow Dr. Nick Mark here.
Nick, I'm going to bring it up on Twitter as we speak,

or next rather. But

you had pointed out,

still Twitter to you, but you had pointed out, I think, in a really compelling way, how no hospital is going to end up paying for a resident that might cost $55,000 a year from a salary perspective.

Now, that hospital previously had to fund a fee,

an H-1B visa fee to bring that FM foreign medical grad into their system to train them.

It was beneficial to the hospital system because those residents effectively were caring for patients, but at a discounted rate versus, say, URI.

But now instead of paying, say, less than $5,000 per foreign medical grad to come into their system, now they're having to pay potentially up to $100,000.

I know that's being maybe potentially revisited. But talk to us about the strain that would put on a hospital system if that turns out to be true.
Right. Great point.

So we should emphasize that resident physicians are kind of the backbone of a lot of hospitals in this country.

You know, when you you and i were in residency together right like we were you know basically like at night we were the doctors in the hospital right that's how the hospital worked and residents typically work

uh i guess we're supposed to work we were supposed to work less than 80 hours per week um that's a theoretic cap but many many people work more than that so basically you know resident physicians work double the normal job and the salary for that nationwide is about fifty five thousand dollars a year and we should say that that is more than the median household income.

But when you consider that these are people who have graduated from college, graduated from medical school, and are working

long hours, nights, and weekends, it's a relatively low wage, right? Now, obviously, this is work that people do as residents,

knowing that later on, once they complete their residency and fellowship, they'll have a higher paying job. But

hospitals really depend on this labor force.

And if hospitals are being asked to suddenly fork over an extra $100,000 per resident who's on one of these H-1B visas, that would be an enormous cost to these hospitals.

And specifically, if you think about some of these rural hospitals that serve more underserved communities, this could be a really catastrophic cost.

Remember that this comes on the heels of cuts to Medicaid, which a lot of these hospitals depend on as well. So these hospitals are already financially strained.

And then being asked to basically pay three times as much for the labor that they depend on,

that's going to break many of them, I fear. Yeah.

No, I mean, you know, I think the latest statistics, this is from Fierce Healthcare citing Pew and some other nonprofits that track this, Taiser Family Foundation.

You know, for all our listeners there out there, 46% of rural hospitals, according to these third-party sources, are in the red. They're losing money every single year for a variety of reasons.

432 across the country, Nick, to your point, a lot of sort of headwinds when it comes to how a hospital balances their budget sheet. The 432 are close to being in the red

and basically putting at risk their future operations.

And here we are now saying that the supply, let's just call it what it is, residents are discounted critical human capital to provide medical services.

And there's all sorts, that's a separate conversation on how do we protect and

make sure that residents are cared for. But this is a critical supply of human capital to care for an aging population just at a time where hospitals are consolidating.

So for all our listeners, you know, we hear about the hospital down the street being acquired by some multi-state conglomerate.

That's happening because most of the hospitals outside the four,

the catchment of a say a big city are struggling. Even the hospitals in a big city like New York City are struggling to turn a profit.
So what happens?

They get bought up by a large multi-state chain or they close or they change or transition pediatric beds to adult beds, which we're seeing, you know, 20% of the absolute number of pediatric beds across the country.

We've lost 20% of that sort of slack in the system since 2008 because of these economics.

What right, there's, there's far much, there's far more money to be made taking care of adults with Medicare than children with Medicaid, right? Exactly.

So as venture capital is buy up hospitals and the goal becomes profit, they shut down pediatric wards. That's exactly right.

What do you think will be the administration's response? So you put, just for our audience, who I teed this up previously, so at Nick M. Mark on Twitter slash X, you can find Nick.

The amount of just incredible content, especially for the clinical community, is unmatched. But I highly encourage everybody to follow Nick and Mark on Twitter/slash X.

On a few days ago, Nick, September 19th, you actually posted at 4:46 p.m.

Pacific, quote, this will be absolutely devastating in the medical field.

Approximately 30% of residents are international medical crash rates, and about 10,000 of the 43,000 residency spots are filled by docs with H-1B visas. You then went through the math of it.

Previously, the H-1B visa fee was about less than 5K. No hospital will pay 100K fee for 55,000 resident salary.
That tweet, I think, had created its own news cycle.

Wondering what you think the administration's response will be. Will they exclude medical providers from this fee increase? What are you hearing? I'm not sure.

I mean, I think, as with everything in the Trump administration, they're kind of making it up as they go along.

So, I mean, I think even between the press conference where they announced this change and then the tweets by the press secretary, there were substantial policy changes.

You know, between is this going to apply to everyone on an H-1B visa every year, or is it only going to apply to new ones?

Today, we're hearing rumblings that this may not apply to physicians, which would be great.

I also just want to emphasize one other point, too, which is that this is going to, this, this is, this goes beyond residence, right? The

U.S. healthcare system really depends on foreign medical grads, both as residents and as attendings.
And, you know, there are a couple of programs that are really designed to do this.

so for example let's say that you come to the u.s and you do your residency under a j1 visa uh which in fact most residents have a j1 visa what's a j1 visa just for uh

a j1 visa is uh it's a visa for studying um as opposed to an h1b visa where uh you can sort of proceed into uh like getting a green card um the j1 visa is basically designed so that you come you do residency and at the end of your residency you have to leave for two years before you can try to come back.

And so, this is unfortunate because it means that we've, you know, we've trained people to be, you know, fully trained physicians, and then they have to leave.

So, one of the programs that the U.S.

has set up is something called the Conrad 30 program, where people who are on a J-1 visa can get that converted to an H-1B visa and stay if they agree to work in a rural underserved community.

So, a lot of medical needs in places like Appalachia are are served by physicians who make this deal, where they basically work in a place where U.S. physicians don't want to work.

And in exchange, they get to stay here after completing their training here. And this is really a win for everybody, right?

This is a win for the physician who wants to stay in this country, presumably. It's a win for the U.S.
medical system who gets a fully trained physician.

And it's a win for the community that can't get a U.S. physician to move there.

I suspect that this fee increase, if it applies to doctors, will also affect these programs and will be catastrophic for these rural healthcare programs.

Nick, I won't pin you on this, but I'll just share.

Because

we took what you did so well, articulating this on social, the potential impacts, especially on the emergency pod we did with Ben on Friday.

Ben had teeth this up for all the Midas Mighty out there, brought Nick's tweet in. I said, gosh, I know that guy.
We talked about it. There was some covers on it.
And,

you know,

I'm used to getting verbal abuse,

you know, all sorts of sort of different invective

sort of tossed my way, given the roles I play in health information across the spectrum.

You should see my DMs after this tweet. All right.
So, well, yeah, I saw a little bit of it. And

I have to say, you know, I'm not surprised by anything. I don't react.
I was tempted to a few times because

the offense I took to listening or to hearing what nativists and racists put out there when it came to, you know, why is my, why is Gupta, of course, Gupta is defending this and yada, yada, yada. And,

you know, you expect that. And if I were to react to every sort of offensive thing, I'd be spending my entire time doing that.
But I

do think there's something that's going to get conflated here. And I just wanted to call it out.
And I say this, my mom was a foreign medical grad. I know a ton of foreign medical grads.

I practice with a few foreign medical grads.

Listen, there's exceptions everywhere. And I'm sure people have had varying experiences with any type of doctor or medical provider health system.
So this is not broadly applicable.

There's always exceptions. But I've never found a foreign medical grad in my personal experiences

who aren't very hardworking. who aren't credentialed and the ones that are working in a hospital

go through the same types of credentials credentials and quality controls that you and I do. And I think it's really important to keep that in mind that these people are here.

Yes, they have, there's an opportunity to improve their life by being in the United States, but they're one, they're needed, and two,

to the best that we can. We control for quality, safety, and credentials, and they really work hard.
And

I think that the lazy take hair is,

and the racist nativist take care is that somehow we're compromising in quality and we're bringing in the second, sort of a second-class citizen to come in and fill the ranks of our hospitals.

I think that needs to stop because I don't agree with that. And yes, there's exceptions.

I'm sure we can all talk about exceptions, but I just wanted to make that comment because I do feel like I saw a lot of those sentiments, negative sentiments. Yeah, let's actually debunk that.

Because I mean, I'm a firm believer that like facts can win arguments. So let's talk about that.
So

I'll just give you sort of a couple of things that I heard kind of mouth breathers in the comments say and kind of my reaction to that. Yeah, please do.
So one is, this is why

my son, daughter can't get into medical school. Right.
And that's just not true, right? There's there's far more

residency spots than medical school spots. Like medical school, medical school is less than 2%.

uh foreign-born people. It's basically all U.S.
born people who attend medical school in the U.S. Most medical schools don't even let you apply if you're not a U.S.
citizen or resident.

So foreign-born people are not taking spots in U.S. medical schools.
Getting into U.S. medical school is competitive.

About two people apply for every one spot, but it's competitive because we want it to be competitive. It's supposed to be hard.
You have to do well to get in.

It's not hard because, quote, foreigners are taking spots.

Another point that you made was this idea that somehow foreign medical grads are less qualified.

I mean,

I think we can give lots of counterexamples, but there are people who do entire residencies abroad and then come to the U.S. and do residency over again because they're so committed to this, right?

Like literally the most qualified resident, first-year resident in the hospital is often an international medical grad who's already done residency abroad and needs to do it over again in the U.S.

to be licensed and practice here. So I think that's just untrue.
It's also worth pointing out that the vast majority of U.S. medical school grads will match into residency.
It's well over 90%,

as opposed to international medical grads where it's less than 60%.

So the competition is way stricter. They're taking the residency spots that by and large Americans don't want, like primary care spots in underserved communities.

And they're doing great work when they're here. You know, if you go to, if you go to, you know, so many hospitals in America, you will find doctors with

foreign last names who came here on these programs and stayed as pillars of those communities, taking care of patients that a lot of American born and trained physicians don't want to.

Beautifully said. Gosh, love that.
And you're right. Facts should

up persuade. They don't always, but

there's probably a doctor you could tell in most hospitals in America, in fact, I would say. That's right.
That's right.

Nick, you know, as we close here, I do want to zoom out for a second.

Midas Health really focuses on public health, health policy, what's happening with the current administration.

We try to focus on the policy, not the person, and scrutinize the policy and try to make whatever is happening at a high level as real as possible to all our listeners.

And, you know, I take, for example, all the turning at the advisory committee on immunization practices and what they're doing.

And, you know,

there's a huge gap between, say, what they're putting out there and understanding potentially how it impacts what you can and cannot receive at your local pharmacy down the street.

And so we're trying to translate that. So people understand,

not, you know, not trying to be presumptuous and paternalistic, but making sure that there's a common understanding on how policy at the highest levels is directly impacting what people can and cannot get access to.

What I love about what you do, it's similar but slightly different,

is is you make us all smarter and your clinical peers. And you do it in a way that,

oh, I just think you do it. And had I without the personal connection, I'd be saying the same exact thing.
I am wondering, though, how you swear what you do so well

with

today's headlines on autism and Tylenol abuse

during pregnancy or getting rid of MMRV or rehashing potentially hepatitis B indications for the birth dose.

When those things are happening when it comes to just fundamental guidelines that, you know, previously were unimpeachable, we didn't revisit that.

How does it affect what you do when it comes to peer education? And how are you wrestling with that? Yeah, it's a good question. I mean,

I think a lot of people who work in the healthcare field are

incredibly frustrated and alarmed by what they're seeing.

You know, so much of the progress that we've made as a profession over the last couple of of centuries seems to be, you know, being undone before our eyes, right?

Like we want to have less safe water supplies. We want to not have vaccines.

You know, just like a lot of the, a lot of the enormous progress that's been made over the last century, it's like, oh, we're going to just undo all of that apparently with government policy.

You know, I'm a firm believer that.

My audience is obviously more medical professionals, not less a general audience.

But, you know, I think some of the same rules apply, which is that facts can win arguments, that educating people and giving them, you know, either the tools to understand the data or the data

is a way to convince people to follow the evidence. And I think that, you know, what you do on this show is exactly that, right? It's not just tell people to

take a vaccine because I'm so important. It's tell people why it's important.
Tell people what the consequences of measles are and why preventing it is so important.

I think that's the only way to prevail against the tides of misinformation is to make people understand why it's misinformation. Beautiful.
Beautiful.

For our audience there, this will not be the last time, presuming he's willing to come back, that we'll have Dr. Nick Mark

with us. Oh, we definitely will.

Now more than ever.

Please, for all those listening, Nick M. Mark on Twitter, X,

Critical Care Care Time

is his podcast, Discoverable, where you get your podcasts. And Nick, I just want to thank you for being here.
Yeah, thank you so much for having me. This is great.
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