• InternatIonal medIcal graduates

InternatIonal medIcal graduates
In amerIcan medIcIne:
Contemporary challenges and opportunities
A position paper by the AMA-IMG Section Governing Council
January 2010
International medical graduates in American medicine i Contemporary challenges and opportunities | January 2010
Table of contents
Page
Acknowledgements.............................................................................................................................................................. 1
Foreword ............................................................................................................................................................................... 2
Introduction........................................................................................................................................................................... 3
Profile of IMGs ...................................................................................................................................................................... 4
Historical context of medical education and migration.................................................................................................... 7
History of the ECFMG ........................................................................................................................................................ 10
Controversies in physician work force recommendations ............................................................................................. 12
Council on Graduate Medical Education...................................................................................................................................... 12
Pew Health Professions Commission .......................................................................................................................................... 12
A consensus statement ................................................................................................................................................................ 12
The Institute of Medicine .............................................................................................................................................................. 13
Managed care............................................................................................................................................................................... 13
Reduce GME funding ................................................................................................................................................................... 13
Physician work force recommendation implications .................................................................................................................... 14
IMG contributions ............................................................................................................................................................... 15
Gap filling or safety net role.......................................................................................................................................................... 15
IMGs in primary care .................................................................................................................................................................... 17
IMGs in academic medicine and research ................................................................................................................................... 19
2009 Nobel Prize scientists .......................................................................................................................................................... 20
Trends among IMG faculty at U.S. medical schools: 1981–2000................................................................................................. 20
Immigration................................................................................................................................................................................... 20
Graduate medical education ............................................................................................................................................. 22
Selecting residency programs ...................................................................................................................................................... 22
ECFMG certification ..................................................................................................................................................................... 22
Applying to graduate medical education programs ..................................................................................................................... 22
National Resident Matching Program .......................................................................................................................................... 23
Obtaining a residency position in the United States .................................................................................................................... 26
International medical schools ....................................................................................................................................................... 27
Observerships .............................................................................................................................................................................. 27
Immigration and visas ........................................................................................................................................................ 29
Temporary worker H-1B visa ........................................................................................................................................................ 30
Immigrant visas ............................................................................................................................................................................ 30
Significant dates in U.S. immigration policy affecting IMGs ........................................................................................................ 30
USIMGs ........................................................................................................................................................................................ 31
Dynamics of migration: Brain drain .................................................................................................................................. 33
Conclusion .......................................................................................................................................................................... 35
Recommendations ............................................................................................................................................................. 36
International medical graduates in American medicine I Contemporary challenges and opportunities | January 2010
Table of contents (continued)
Page
IMGs in organized medicine .............................................................................................................................................. 37
2009–2010 AMA-IMG Section Governing Council ....................................................................................................................... 37
State medical societies with IMG sections................................................................................................................................... 37
References .......................................................................................................................................................................... 38
Additional recommended resources ................................................................................................................................ 41
Appendix A: Index of tables and graphs .......................................................................................................................... 42
International medical graduates in American medicine II Contemporary challenges and opportunities | January 2010
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Acknowledgements
The American Medical Association (AMA) International
Medical Graduates (IMG) Section Governing Council
would like to acknowledge the valuable contributions of
the following individuals, without their expertise and
commitment, this paper would not be possible.
Nyapati Raghu Rao, MD, chair of the AMA-IMG Section
Workforce Paper Committee, Department of Psychiatry and
Behavioral Sciences, Nassau University Medical Center, N.Y.
Rajam Ramamurthy, MD, AMA-IMG Section Workforce
Paper Committee member, neonatologist, San Antonio
Mitra Kalelkar, MD, AMA-IMG Section Workforce Paper
Committee member, deputy medical examiner,
Cook County, Ill.
Jayesh Shah, MD, AMA-IMG Section Workforce Paper
Committee member, AMA-IMG Section Governing Council
chair, hyperbaric medicine, San Antonio
VijayaLakshmi Appareddy, MD, AMA-IMG Section Work-
force Paper Committee member, psychiatrist, president of
Tri-State Psychiatric Services, Chattanooga, Tenn.
Raouf Seifeldin, MD, AMA-IMG Section Workforce Paper
Committee member, AMA-IMG Section Governing Council
vice-chair, family medicine, Pontiac, Mich.
Padmini Ranasinghe, MD, AMA-IMG Section Workforce
Paper Committee member, AMA-IMG Section alternate
delegate to the AMA House of Delegates, internal medicine,
Johns Hopkins, Baltimore
Jack Boulet, PhD, associate vice president, research and
data resources, Foundation for Advancement of International
Medical Education and Research, Philadelphia
International medical graduates in American medicine 1 Contemporary challenges and opportunities | January 2010
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Foreword
International medical graduates (IMGs) have been an inte- the entry of approximately 6,000 IMGs into the United States
gral part of American medicine since the late 1940s. These every year contributes a few billion dollars to the U.S.
graduates arrived in America from more than 125 countries economy, which is equal to the output of 50 additional
with varying cultural and linguistic backgrounds in search medical schools without any cost to the taxpayer.
of advanced knowledge and skills in medical institutions of
higher learning. In looking at the challenges they face, the It becomes evident that the story of IMGs is a very complex
sacrifices they make, the disappointments they encounter one indeed, and in this document, the American Medical
and the successes they achieve, the IMG journey is often Association (AMA) IMG Section committee will provide a
arduous and heroic. comprehensive review of IMG literature. The background of
this document begins with Rajam Ramamurthy, MD, who
In the words of Jordan Cohen, MD, former president of the served as chair to the AMA-IMG Governing Council from
Association of American Medical Colleges, “Indeed, examples 2004 to 2005. During her tenure, the governing council
abound of IMGs who have improved health care delivery, addressed the issues related to IMGs’ role in the U.S. physician
provided care to underserved populations, made ground- work force by creating a document titled “IMGs in American
breaking discoveries in biomedical research, introduce new medicine: A discussion paper.” This paper was updated annu-
surgical techniques, pioneered innovative teaching methods, ally by each year’s governing council’s work force committee.
and more” (Jordan, 2006). And he is correct—there are In view of dramatic changes taking place with the nation’s
multiple facets to the IMG story. health care reform and the expansion of U.S. medical school
output, the discussion paper was subjected to a thorough
Among all advanced nations, America is the most welcoming revision this year. Its title was also slightly changed and is
country to IMGs. Nonetheless, the presence of IMGs in now “International medical graduates in American medicine:
America has raised questions about the soundness and Contemporary challenges and opportunities.”
adequacy of IMGs’ medical education, the quality of the
medical care they deliver, their contribution to increasing This paper begins with a description of the history of IMGs in
the physician supply and deepening the physician maldistri- the United States in the context of the evolution of graduate
bution and finally, causing brain drain. On the other hand, medical education. It reviews the controversies surrounding
IMGs often feel perplexed, overwhelmed and discriminated physician supply, as well as IMGs’ role in health care delivery.
against, although they also feel appreciative of the It presents the current demographics in the IMG work force,
opportunity to receive world-class medical training. highlighting the resilience of IMGs. In addition, the paper
discusses issues concerning brain drain and the IMGs’ role
To start, IMG presence in the United States is the latest in the organizational structure at the AMA. The discussion
episode in “medical migration,” which is an age-old concludes with recommendations stemming from the issues
phenomenon. From the Civil War to World War II, Americans discussed. Topics were chosen to reflect major priorities in
went abroad for advanced medical education and brought the professional and educational life of IMGs.
back new knowledge and skills that improved the way
American medicine was practiced and taught. Now America In spite of our best efforts, it is very difficult to comprehensively
hosts physicians from all over the world seeking similar address all topics that pertain to IMGs in a single document.
opportunities, even though a majority of these international One may find that some topics lack depth, while others might
graduates do not return to their native lands after require further elucidation. As editor of this document, and as
completion of their training. chair of the AMA-IMG Section Workforce Paper Committee,
I found the experience extremely stimulating and enriching.
Understandably there are considerable concerns over the I thank members of the work force committee for the
“brain drain” phenomenon—that is, depleting poor nations generosity of their time and efforts, and AMA staff, led by
of their scarce physician resources. At the same time, some J. Mori Johnson and Carolyn Carter-Ellis, for their extraor-
feel there is insufficient appreciation of American values, dinary support of this project. They gave me a free hand in
quality control systems and American currency, all of which the choices made, participated in multiple phone calls and
help to improve the living conditions and the manner in submitted their contributions with great enthusiasm.
which medicine is practiced and taught in foreign countries.
This cultural and educational exchange is perhaps the most Nyapati R. Rao, MD, MS
beneficial, but intangible, aspect of IMG and U.S. interaction. Chair, AMA-IMG Section Workforce Paper Committee
The value of this exchange is equal to the work done by Chairman, Department of Psychiatry and Behavioral Science
thousands of U.S. Peace Corps volunteers in all corners of the Chief academic officer, Nassau University Medical Center
world without a single penny spent by taxpayers. In addition,
International medical graduates in American medicine 2 Contemporary challenges and opportunities | January 2010
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Introduction
Medical migration, the phenomenon of physicians traveling
far and wide in search of new knowledge and skills, has been
practiced for several centuries. China, Great Britain, France,
Germany and now the United States have all attracted inter-
national students at different times by their dominance of
medical education and practice. In the 19th century, Ameri-
can physicians traveled to Europe, especially France and
Germany, to pursue medical education. When they returned,
the knowledge and skills these physicians brought back to
the United States profoundly changed medicine in America
(Baron, 2005). Since the end of World War II, the United
States has been the preferred destination for physicians from
all over the world for training in graduate medicine. However,
these recent international physician visitors differed from
previous generations in that they frequently did not return
to their native country—instead, these physicians made the
United States their home.
Physicians who received their undergraduate medical
education outside of the United States and Canada are
referred to as international medical graduates (IMGs).
IMGs are a heterogeneous group from more than 127
nations with varying cultural and linguistic backgrounds,
and they are critical to delivering health care in the United
States. In 1963, IMGs represented slightly more than 10
percent of the physician work force in the United States.
Today, they comprise 25 percent of the U.S. physician
population.
In the following pages, the American Medical Association
(AMA) IMG Section Workforce Paper Committee will
examine various aspects of the IMG presence in the U.S.
physician work force. There are several purposes for writing
this position paper. First, we want to tell the story of IMGs.
We also seek to offer our perspective on some of the issues
that confront IMGs in order to place IMG presence in a
historical context, to clarify misconceptions, to highlight
IMG contributions, and to confront unfair and biased
criticism wherever it occurs.
International medical graduates in American medicine 3 Contemporary challenges and opportunities | January 2010
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Profile of IMGs
An examination of IMG demographics reveals that a Germany 4,197 1.7%
majority of present-day IMGs are clinicians. According to Syria 3,869 1.6%
Jordan Cohen, MD, and Fitzhugh Mullan, MD, 25.8 percent
United Kingdom 3,698 1.5%
of total physicians are in patient care (Jordan, 2006) (Mullan,
Montserrat 3,569 1.4%
1995). Within the IMG physician population, 77.5 percent
are in patient care. Of these IMGs (188,638), nearly three- Colombia 3,343 1.3%
quarters are office-based physicians. In addition, one-fifth Ireland 3,302 1.3%
of all physicians are in research (19.6 percent), and 1 out of American Medical Association Physician Masterfile, 2009
6 physicians who are in medical teaching (16.8 percent)
were IMGs. Only 13.5 percent of all physicians are in
Table 3
administration. Twenty percent of all IMGs are in
Top 20 states where IMGs practice, 2007
research and 13.5 percent are in administration.
Percentage of total
state total number of Imgs physician work force
Table 1
General IMG statistics, 2007 1. New York 35,934 42%
2. California 26,209 23%
Number of physicians in U.S. 941,304 3. Florida 20,243 37%
Number of IMG physicians 243,457 (from 127 countries) 4. New Jersey 13,824 45%
% IMG physicians in U.S. 26.0 5. Texas 13,705 24%
% IMGs in residency programs 27.8 6. Illinois 13,698 34%
% IMGs in primary care 58.0 7. Pennsylvania 11,231 26%
% USMGs in primary care 26.0 8. Ohio 10,046 29%
% IMGs in patient care 73.0 9. Michigan 9,749 34%
% IMGs in academics 14.0 10. Maryland 7,262 27%
Percentages exclude resident/fellows unless otherwise stated 11. Massachusetts 7,377 22%
Physician Characteristics and Distribution in the U.S., American Medical Association, 2009
12. Virginia 5,197 22%
IMGs are chiefly concentrated in New York, California, 13. Georgia 4,597 20%
Florida, New Jersey and Illinois. The top five countries of 14. Connectcut 4,339 29%
origin among IMGs are India, The Philippines, Mexico,
15. Missouri 3,600 22%
Pakistan and the Dominican Republic.
16. Arizona 3,461 22%
17. North Carolina 3,393 13%
Table 2
18. Indiana 3,238 21%
Top 20 countries of medical education for IMG physicians
% of total IMG population (number of physicians) 19. Tennessee 3,069 17%
20. Wisconsin 3,075 19%
country total Percentage Physician Characteristics and Distribution in the U.S., American Medical Association, 2009
India 51,447 20.7%
Philippines 20,601 8.3%
Table 4
Mexico 13,834 5.6% Primary specialty of IMGs, percentage in specialty
Pakistan 12,111 4.9% (number of IMG physicians)
Dominican Republic 7,979 3.2%
Internal medicine 37% (58,818)
Grenada 6,749 2.7%
Anesthesiology 28% (11,717)
USSR 6,450 2.6%
Psychiatry 32% (13,146)
Dominica 5,854 2.4%
Pediatrics 28% (20,647)
China 5,375 2.2%
Family medicine 27% (23,111)
Egypt 5,266 2.1%
Obstetrics/gynecology 17% (7,465)
Iran 4,940 2.0%
Radiology 19% (1,681)
South Korea 4,845 2.0%
General surgery 20% (7,353)
Italy 4,732 1.9%
Physician Characteristics and Distribution in the U.S., American Medical Association, 2009
Spain 4,343 1.8%
International medical graduates in American medicine 4 Contemporary challenges and opportunities | January 2010
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Table 5
IMGs by age and major professional activity, 2007
Under 35
13.2% Hospital-based
Over 65 23.3%
Patient care
21.8% 80.1%
35–44
23.3%
55–64 All other
19.8% categories
21.8%
Of ce-based
57.9%
45–54
22.0%
IMGs by age IMGs by activity
Physician Characteristics and Distribution in the U.S., American Medical Association, 2009
Nearly twice as many IMGs were in the 35 to 44 age group in influence on younger colleagues who are in residency
2007 than in the under-35 age group. Female IMGs constituted training. On the other hand, the graying of the IMG population
30.6 percent of the IMG complement. In other words, 87 per- may presage their ultimate extinction from the physician
cent of IMGs are 35 years and older and, in this aspect, are work force, which could have significant public health
more similar in age to a second-career physician among U.S. ramifications.
medical graduates (USMGs). The implications of this fact are
important. For example, a more mature IMG, while carrying Nearly three-fifths of IMGs are in the following specialties:
out his patient care activity with a greater sense of responsi- internal medicine, pediatrics, family medicine, psychiatry,
bility than his younger colleague, may exert a stabilizing anesthesiology, obstetrics-gynecology, general surgery
and cardiology.
Table 6
IMGs by gender and self-designated specialty, 2007*
Psychiatry
Pediatrics
Pathology-Anatomy/Clin.
Obstetrics/Gyn.
Internal Medicine
General Surgery
General Practice
Male
Family Medicine
Female
Anesthesiology
0 5,000 10,000 15,000 20,000 25,000 30,000 35,000 40,000 45,000
Physician Characteristics and Distribution in the U.S., American Medical Association, 2009
International medical graduates in American medicine 5 Contemporary challenges and opportunities | January 2010
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Table 7
Percentages of IMGs in highest IMG self-designated
specialties, ranked by size, 2007
total Img (%) rank
specialty 1980 2007 1980 2007
Internal medicine 13.4% 24.2% 1 1
General/Family medicine 9.4% 9.5% 2 2
Pediatrics 6.8% 8.5% 5 3
Psychiatry 7.0% 5.4% 3 4
Anesthesiology 6.0% 4.8% 6 5
Obstetrics/gynecology 5.4% 3.1% 7 6
General surgery 6.9% 3.0% 4 7
Cardiovascular disease 2.3% 2.8% 9 8
Pathology 4.0% 2.6% 8 9
Physician Characteristics and Distribution in the U.S., American Medical Association, 2009
The presence of IMGs has been controversial on many levels.
Questions have been raised about the quality of care IMGs
deliver and their contributions to physician maldistribution
and physician surplus. Approximately 75 percent of all physi-
cians who train in the United States ultimately establish their
practices here and, in this regard, they differ from physicians
in earlier generations (Mullan, 1995). Some believe that this
tendency of IMGs to permanently reside in the United States
contributes to a physician surplus, and consequently, have
called for limiting IMGs’ entry into graduate medical edu-
cation (GME) and eventually to lower the number of IMGs
among practicing physicians (Education & Report, 1998).
Additionally, some doubt the quality of IMGs’ medical
education and their capacity to function as physicians in the
United States (Torrey, 1973). Others believe that IMGs, by
seeking training in certain specialties, worsen the problem
of physician maldistribution in the United States (Mullan,
1995). Finally, there is the issue of brain drain—impoverished
nations losing their precious, educated human talent to the
West. This is a topic that has been extensively commented
upon in the recent professional literature (Mullan, 2005).
Other researchers counter these arguments by stating that
IMGs perform a unique safety-net function by caring for the
uninsured and the indigent populations in inner city and
rural areas, in contrast to U.S. medical graduates (USMGs)
(Mick, 2000) (Baers, 1998). Similarly, Mick contends that the
allegation of inferior performance by IMGs is questionable
(Mick, 1997).
International medical graduates in American medicine 6 Contemporary challenges and opportunities | January 2010
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Historical context of medical education and migration
The history of IMGs in the United States is closely ences of French medicine acted as an antidote to “outlandish
intertwined with the evolution of the country’s medical theories and speculative abuses” that existed in American
education, and in the following pages, the major themes in medicine. American physicians were greatly influenced by
GME will be discussed to provide an understanding of IMGs’ the French methods in that they practiced observation and
entry and continued presence in the U.S. physician work distrusted experimental research and laboratory medicine.
force. This historical context is critical to appreciating and
understanding the issues faced by IMGs today. GME in By the middle of the 19th century, however, French medicine,
the United States evolved from being a loosely structured due to its lack of research basis and its disdain for biological
experience to a highly regulated and closely monitored sciences, caused its own downfall from its preeminent posi-
system of graduate education of physicians, where even the tion and consequently lost its allure for American students.
number of hours they sleep is under scrutiny. IMGs leave Instead, Americans turned to Germany, which had become
behind their own disparate systems and must confront this the center of European medicine. They were attracted by
orderly clinical teaching enterprise of GME, which is vastly Lehrfreiheit, or “freedom of teaching,” and Lernfreiheit,
different from their own. (The review of the history of GME “freedom of learning”—the twin principles of German educa-
is obtained primarily from Kenneth Ludmerer’s landmark tion. In addition, some of the features of German education,
publications, Learning To Heal and Time to Heal.) such as full-time salaried professors, division of education
into undergraduate and postgraduate domains, creation of
In mid-19th century, America was ravaged by infectious specialties and subspecialties, and an emphasis on laboratory
diseases, and medications were not available, with the science (all too common in the U.S. now, but novelties at the
exception of chloroform and ether for anesthesia, and time) also attracted Americans. All these developments set
quinine to treat malaria. Amputation was the standard the stage for the evolution of academic medicine around
treatment for injured limbs, and the poor quality of surgery the activities of the medical school located in the university.
is reflected in an 87 percent mortality rate of all amputations These students returned to the United States to practice their
conducted during the Civil War. In contrast, there was only new skills and, in this regard, were different from the IMG
a 3 percent mortality rate for this procedure in World War II. physicians of the 21st century, who come to the United States
Elementary techniques of the physical exam, such as measur- and generally stay here.
ing temperature, percussing the chest or using stethoscopes
or ophthalmoscopes were done by very few physicians. In Despite these positive developments, there were still
1800, only three medical schools existed: the University of many problems with the system due to lack of uniform
Pennsylvania, Harvard Medical School, and King’s College standards and requirements. Medical education was a
(now Columbia University). Instruc