Newly licensed doctors enlisting to treat the state's Medicaid and Medicare patients are more likely to have been trained at international medical schools, according to a review of state medical licensing data.Of the roughly 1,500 doctors who have received fast-tracked licenses in the last three years in exchange for agreeing to treat the state's neediest patients, nearly 40 percent were trained at international schools, everywhere from India and Mexico to Uzbekistan and Rwanda, and a quarter were trained in Texas. The Texas Medical Board fast-tracked more licenses for doctors trained in Pakistan than it did for those educated in Louisiana or Oklahoma.Internationally educated doctors are nothing new in Texas. Doctors trained outside the U.S. or Canada already make up more than a fifth of the state's licensed physicians and more than a quarter of the new doctors licensed every year. They're essential to the state's medical work force; in the midst of a national primary-care shortage, they sustain everything from Texas' public-health clinics to its rural doctors' offices."The impact is not only in Texas, but nationwide," said Dr. Ashok Kumar, president of the Texas Academy of Family Physicians and an international graduate. "These are the doctors who are going to serve Texas' rural patients, urban patients, underserved patients."As more longtime doctors stop seeing money-losing Medicaid and Medicare patients, the result of far-from-adequate federal and state reimbursement rates, the burden will increasingly fall to international graduates.Serving the poorMany have visas that are contingent upon their work with poor and underinsured populations in cities and small towns.With healthcare reform expected to push an estimated 1 million new Texans onto state Medicaid rolls, the pressure on the doctors who accept these patients will only mount.International doctors come to Texas not only because it's a big state with a lot of opportunities, but also because they're recruited here. Medical schools, veterans hospitals and group practices in search of a particular kind of physician often help international graduates get visas, sometimes with strings attached.To be licensed in Texas, these graduates must go through a rigorous and lengthy process, including getting three years of postgraduate training in the U.S. and proving that their medical education was "substantially equivalent" to the education provided in an American or Canadian school.Many international schools are preapproved; others require mounds of paperwork and months upon months of review, which Kumar says leads some young doctors to go to states with less stringent procedures.So when the Texas Medical Board offers to help doctors cut through the red tape in exchange for their agreement to take government-subsidized patients, it's no surprise that many international graduates jump at the chance."They self-select to do that, because they know their applications as a rule take longer to process," said Jaime Garanflo, the medical board's director of licensure.Agreeing to treat Medicaid and Medicare patients, or to practice in an underserved community, is also a fast way to build a practice and credibility, says Jose Camacho, executive director of the Texas Association of Community Health Centers, which represents providers and federally funded clinics that treat the uninsured and underserved.Cultural barriersBut Camacho says that these doctors vary in their success -- and that sometimes the cultural barriers they face are insurmountable.In one case, a Middle Eastern doctor came to practice at a federally financed clinic only to find that the facility's executive director was female. He left, saying that, in his country, men didn't take orders from women. On the other end of the spectrum, Camacho says, is an Indian doctor placed in Brownsville who learned to speak Spanish and had Indian spices mailed to him from Texas' big cities so he never felt too far from home. "We often talk about being culturally sensitive to our patients," Camacho said. "The reverse is also true. We have to be culturally sensitive to the providers' needs."