Najwan Al Ani sits in her El Cajon apartment and flips through a tattered study guide for the first phase of the United States Medical Licensing Examination. After she used the workbook to study for and pass the test in 2011, it's less a book and more a messy stack of pages saturated with highlighter ink.
But Al Ani keeps it as a souvenir to commemorate her first stop in a years-long and nearly $10,000 journey to practice medicine again.
The Iraqi refugee spent seven years as a primary care physician in Iraq and Jordan. In the United States, she's starting at what seems like square one.
Despite a call for more doctors and nurses to help providers keep pace with the Affordable Care Act, foreign-trained doctors must redo a significant portion of their training before becoming full-fledged doctors again in the United States. They must pass three American licensing exams and compete for residency positions with fresh-faced medical school graduates -- a process that often takes six years or more.
Al Ani's experience treating shrapnel wounds and delivering babies in a war zone doesn't put her at the front of the line.
"Sometimes we faced lack of electricity while we were working," Al Ani said of her two years working at a Baghdad hospital. "Especially for me, I faced a case of delivery without any electricity. I need just single flashlight to make this mom pass the delivery safely for her and her baby."
Al Ani said she and her colleagues worked under intense pressure during the early years of the Iraq War. Medicine and supplies were limited. The streets surrounding the hospital were so dangerous her chief resident was killed on the way to work.
Now in the U.S., she's confronting those experiences once more, translating them for cover letters and mock interviews.
"In war circumstances, you face a lot of injuries, a lot of emergencies," Al Ani said. "This increases your skills, your confidence and your ability to work as a team."
Sophie Cheetham is helping Al Ani navigate the U.S. job market.
"The path is long, it's arduous, it's incredibly costly," Cheetham said.
She runs the Bridge to Employment program through the International Rescue Committee. Each year it offers grants, job-readiness training and guidance to 75 foreign-licensed medical professionals who want to get back into the health care industry.
It's common for many refugee medical professionals to take jobs as taxi drivers and cashiers when they first arrive in the U.S.
"They want nothing more than to find employment to support their families, to lead self-sufficient lives," Cheetham said. "So recertification isn't initially a priority for them."
Cheethum said her clients gain insight into the U.S. work culture through those early jobs. But for a nation already lacking about 16,000 primary care physicians, the benefit of having doctors drive people to the airport or run a checkout stand is less clear.
"What can I say? We need primary care physicians," said Stephen Hayden, who runs UC San Diego's medical residency program. "Everybody knows that and everybody says that."
Hayden said many of the nation's primary care residency positions go unfilled each year because the line of work isn't considered lucrative enough to pay down student debt, which can be near $200,000.
He said it might make sense to fast-track doctors like Al Ani, who's already expressed an interest in practicing family medicine and whose schooling was paid for by the Iraqi government.
"They will still have to complete, at least with the current structure and rules, a primary care residency of some sort, but especially given that some of these slots are more difficult to fill, I think that it wouldn't be unreasonable to consider a program where those individuals would fill some of those slots," Hayden said.
But streamlining the process for refugee doctors could be a tricky line to walk. Despite the trouble filling primary care residencies, Hayden said competition among U.S. med students is high; the number of U.S. medical school graduates is projected to exceed the number of residency slots available by 2015.
There were 34,355 graduates vying for residencies this year -- up 3,000 from 2012 -- according to the National Resident Matching Program, which oversees the placement of all residency applicants in the U.S.
At 7,568, the number of international medical graduates without U.S. citizenship applying for a spot has increased three-fold since 1991. Less than half obtained positions this year, according to the NRMP.
But, as Al Ani clicks through an online residency application system in her El Cajon living room, she projects an unfaltering calmness. She said she doesn't mind being thrown into an overflowing applicant pool with graduates ten years her junior. And she doesn't mind the three years she spent relearning diseases, treatments and procedures.
"In the medical field, you always feel like you are learning. It's a continuous learning for anybody," said Al Ani, who will learn whether she's accepted into a residency program in March. "To work with people who are fresh graduated, I can be helpful with my experience. They could be helpful with their fresh knowledge. I think we will be a good team together. After all, it will be good for the hospital and the patients."