Is the Need for Foreign Graduates Changing?

International medical graduates (IMGs)—physicians with degrees from foreign medical schools—may be facing some fundamental challenges in their role in the US healthcare system.

For more than half a century, there has been a mutually beneficial relationship between IMGs and the residency training system. Programs have more positions than US graduates, so IMGs are needed to fill in the gap. For their part, IMGs are attracted to a US healthcare system that may often be more advanced than their own. Though many IMGs go back home after training, many others apply for residency positions to get into the US system.

IMGs have been able to count on a relatively abundant number of residency positions that can’t be filled by US graduates. In academic year 2014-2015, for example, there were 21.7% more slots than US seniors, according to a November 2015 report[1]published by some top physician-supply experts in the New England Journal of Medicine.

In the future, however, it may be harder for IMGs to get those positions, owing to a huge increase in the number of US medical school graduates, the authors wrote. Since 2002, 16 new allopathic and 15 new osteopathic medical schools have opened in the United States, and many existing schools have expanded class sizes. By the time all of the new US students get through the pipeline, medical school enrollment in the states will have risen by almost 50%, they wrote.

The problem for IMGs is that it’s hard to grow the number of residency positions to meet this surge, so that they can have the same number of slots as before. Medicare, the chief funder of residency positions, hasn’t increased the number of funded positions since 1997.

However, the situation for IMGs isn’t as dire as many people think, the authors reported. Although Medicare lags, other funding sources are stepping up to the plate. For example, a bill passed by Congress in 2014 to reform the Veterans Health Administration will provide 1500 more training slots. As a result, the authors forecasted that the proportion of slots available to non-US graduates would indeed shrink, but is far from disappearing—dropping from 21.7% of positions in 2014-2015 to 13.5% by 2023-2024.

So far, however, the big squeeze on IMGs has yet to materialize. The National Resident Matching Program reported[2] that the 2015 Match offered a record number of positions and was the best ever for IMGs, and the match rate for US-citizen IMGs was the highest since 2005.

But as US schools continue to increase their graduating classes, IMGs are expected to feel the pinch. Furthermore, IMGs from many foreign schools could become completely locked out of the US system in the next decade. The Educational Commission for Foreign Medical Graduates (ECFMG) has announced[3] that in 2023, it will require all applicants to have graduated from schools that have been accredited by standards that are equivalent to those used for US schools. To achieve this standard, the ECFMG will be evaluating accreditors for hundreds of schools around the world.

Having to Exceed US Standards
Even today, when there’s a relative abundance of residency slots for them, IMGs still have to clear a set of hurdles to break into the US system, and only a minority of applicants will succeed.

First, they have to take the United States Medical Licensing Examination (USMLE), testing them for a somewhat different style of medicine than they were used to back home. What’s more, many IMGs who are citizens of other countries (foreign IMGs [FIMGs]) have to take the test in an unfamiliar language.

After ECFMG certification, IMGs have to be accepted into a US residency program. Again, only about one half get a residency slot, according to the National Resident Matching Program, which oversees placement of applicants into residency programs.All IMGs who pass the USMLE have to be accepted to the ECFMG, which verifies their medical education and issues certificates based on USMLE performance. Only about one half of ECFMG applicants get certified.

FIMGs have the further burden of being unknown entities when they apply for residency programs. In many cases, they haven’t had a US clerkship and may not know a US physician willing to write them a recommendation letter, both of which are important criteria for the program directors choosing positions.

Because they’re almost completely unknown, IMGs have to stand out in some way—which usually means being “academic rock stars,” according to Geoffrey A. Talmon, MD, director of the pathology program at the University of Nebraska Medical Center.

For these reasons, FIMG applicants need to have higher scores on the USMLE than US graduates. A 2009 study[4] found that FIMGs have higher scores than USIMGs on Step 1 and Step 2 (Clinical Knowledge)—though not on Step 2 (Clinical Skills), which includes tests of spoken English and communication skills.

FIMGs may even outperform US graduates when they enter medical practice. A 2010 peer-reviewed study[5] found that among patients with congestive heart failure and acute myocardial infarction, those treated by FIMGs had lower mortality rates than those treated by graduates of US medical schools. The study was led by John J. Norcini, PhD, president and CEO of the Foundation for Advancement of International Medical Education and Research, which consists of organizations that certify the competency of US doctors. These groups include the Federation of State Medical Boards, the National Board of Medical Examiners, the Association of American Medical Colleges (AAMC), and the American Board of Medical Specialties.

“We have been blessed with the cream of the crop of the doctors from other countries,” says Dr Norcini, who previously oversaw clinical evaluation at the American Board of Internal Medicine.

Breaking Into the US System Has Always Been Hard
IMGs often have to take extra steps to ensure entry into the US system. Busharat Ahmad, MD, a retired ophthalmologist who helped found the IMG Section of the American Medical Association (AMA) in the 1990s, recalls that he didn’t get into the US system in one easy step.

Dr Ahmad was part of the first great wave of IMGs into the US in the 1950s. He came here hoping to train in ophthalmology after graduating from the University of Karachi in Pakistan in 1956. “I got a couple of responses, but no dice,” he recalls. He was told it was impossible for an IMG to get into a US ophthalmology program. However, he tried a program in London and was accepted there. On the strength of the British diploma, he was able to get into an ophthalmology program in St Louis and, finally, into one at Harvard.

Getting into the US system is still a difficult task for IMGs today. Because their educational backgrounds are often viewed here as being unclear, and because they often lack a favorable letter of recommendation from a US physician, “It’s harder to get a sense of their medical reasoning abilities and procedural skill sets from the standard outside documentation,” says Dr Talmon, the pathology program director.

“So when we look at foreign-national IMGs,” he continues, “we tend to look at only the very best.” These applicants have very high USMLE scores and high grades, or have done research work at a world-class institution. Many other program directors feel this way, too. A 2010 study[6] found that when psychiatry and family practice programs were given identical applications, they were 80% more likely to respond to US seniors than to IMGs.

The higher bar for FIMGs means they have to work harder and do more. Writing in 2011, Kenneth Christopher, MD, a nephrologist who is assistant director of the Preliminary Residency Program at Brigham and Women’s Hospital in Boston, estimated that whereas most US seniors take about 4 weeks to study for Step 1 of the USMLE, some IMGs study for 2 focused years.[7]

Carl Shusterman, an immigration-law attorney in Los Angeles, reports that many FIMGs arrive in the US on student visas 2 years before applying for programs, so that they can take prep courses for the USMLE at such companies as Kaplan. They also try to get paid observerships and externships at hospitals, so that they can gain some clinical experience and make contacts with physicians. In addition, they may take research positions in the United States as another way to stand out when they contact program directors.

But many don’t make it. “I spent close to US $18,000 [and] wasted 2 years,” a Pakistani IMG who failed to get a match wrote[8] on a website for IMGs in 2013. “My fiancée of 5 years almost left me and it was very hard convincing her to stay.”

Shut Out of the System for Good
Whereas many IMGs go back home after they fail to get a residency position, many others stay in America. In many cases, their spouses are US citizens or hold green cards, or they’ve obtained refugee status, according to José Ramón Fernández-Peña, MD, associate professor of health education at San Francisco State University.

Dr Fernández-Peña, an IMG from Mexico who made it into the US system, is the founder of the Welcome Back Initiative, a nonprofit organization that helps doctors and other healthcare professionals educated abroad find work here. Despite their healthcare training in their native countries, most of these people wind up doing menial work when they arrive in the United States, such as driving taxis or working as janitors, Dr Fernández-Peña says. “Highly trained people are sitting around unable to use their expertise. It’s a great waste of brainpower.”

Welcome Back helps many participants find healthcare work, but it’s much harder to help foreign doctors get into their profession. Of more than 4600 foreign-trained physicians who have participated in Welcome Back, only 130 have subsequently won US residency slots, Dr Fernández-Peña reports. That translates to a success rate of under 3%.

These IMGs get shut out of the system quickly, often because they didn’t understand how it works, Dr Fernández-Peña says. For example, many decided to take the USMLE without adequate study. If they fail, they can try again, but the initial score goes onto their permanent record. Even if they score well later, their chances of getting into a residency are almost zero.

Dr Fernández-Peña helped found a free program for Spanish-speaking IMGs at the University of California, Los Angeles. Entrants get test-preparation courses and clinical observerships to help them get into the US system, and in return, they agree to spend 2-3 years in family medicine programs that treat underserved populations. But owing to the cost of the program, just a few slots are available, which hardly puts a dent in the need for Hispanic doctors in California. Dr Fernández-Peña says that although 35% of Californians are Latino, only 5% of California doctors share their ethnicity.

Doctors from the Middle East are another group of IMGs who fall into limbo here, according to Wael Al-Delaimy, MD, an Iraqi-born IMG who works in the Department of Family Medicine and Public Health at the University of California, San Diego.

Many of these IMGs “came here in mid-career as refugees with a green card,” he says. “They had no job and no income, and that’s devastating on multiple fronts. Imagine, you were the lead surgeon at home and now you have become an assistant to an assistant.” He tries to find contacts for these doctors with US training programs—he helped host a jobs forum for about 50 FIMGs last year—but he says it remains an uphill struggle for these doctors.

Gaining Entry Via Caribbean Schools
An increasing number of IMGs entering the US system are US citizens, mostly from medical schools in the Caribbean. The oldest Caribbean schools—St George’s University School of Medicine and Ross University—were founded in the late 1970s, when it was becoming more difficult to get into US medical schools. Students with grade point averages and scores on the Medical College Admission Test that would have gotten them into US schools only a few years earlier found themselves shut out.

Today, the competition for enrollment in US medical schools may be even more intense. The AAMC reported[9] in 2013 that a record number of people applied to US medical schools, yet despite an increase in the number of positions available, only 41% of applicants were accepted. About 28,000 students who had planned a medical career were turned away from US schools.

Some of these students apply to Caribbean schools, which have been growing rapidly. The ECFMG’s 2014 Annual Report[4] shows that the number of ECFMG applicants from Caribbean schools doubled from 2000 to 2013, and USIMGs now account for almost one third of ECFMG certificates.

Fully 31 medical schools in the Caribbean cater to US students, and the flow of graduates back to the United States has been growing, according to the AAMC report. The quality of Caribbean schools varies. A peer-reviewed study[10] of Caribbean schools led by Dr Norcini found that the rate of a school’s graduates getting ECFMG certificates ranged from 28% to 86%. Many of the established Caribbean schools, such as Ross and St George’s, were at the top end.

Working Hard to Erase a Stigma
Caribbean schools have been champing at the bit to prove their quality. Accreditors of Caribbean schools have been at the forefront of qualifying for the ECFMG’s new accreditation standards. In 2015, with the deadline for approval still 8 years away, the ECFMG announced[11] that the accrediting body for several Caribbean schools was one of only three accreditors to be approved so far.

USIMGs have a leg up on graduates from other foreign schools because their schools closely imitate US schools. The USIMGs’ schools have basically the same curricula, employ US-trained faculty, and even send their students to clinical clerkships in the states. They tend to go to clerkships in New York State, where the state Department of Health takes on the unusual role of monitoring the quality of these clerkships.

In US clerkships, students can audition for US-based physicians, who may write letters of recommendation for them for training programs. FIMGs, in contrast, rarely are able to enter US clerkships and are always struggling to find US doctors who could recommend them.

US program directors who screen applicants for the crucial step of residency training like being able to assess an education similar to that of US graduates, says Dr Talmon. “I don’t treat USIMGs any differently than medical students from US schools,” he says. “When they come into the program, I can’t tell the difference from the US graduates.”

Program directors’ greater familiarity with USIMGs’ experiences may explain why USIMGs have somewhat better odds of being matched to a residency program than do FIMGs: 53.1% for USIMGs in 2015 compared with 49.4% of FIMGs, the ECFMG reports.[12]

Whereas some program directors require a minimum score on the USMLE—typically around 230 or 240 out of a perfect score of 300—Dr Talmon isn’t so hung up on scores. “The USMLE was initially designed as kind of a driver’s license test, in which passing or failing was the important thing,” he says. “If you get just a few answers wrong, it can have a huge impact on your score.”

According to recent statistics, USIMGs fit very well into US workforce needs. When they go into practice, they fill in the gaps in primary care even better than FIMGs or DOs. A 2013 report[13] found that 56.7% of Caribbean-educated USIMGs chose a primary care specialty, compared with 54.0% of osteopathic graduates, 42.3% of non-Caribbean IMGs, and 32.9% of graduates from US allopathic schools.

Having a Limited Set of Choices
When IMGs actually get into residency, they find that their career choices are decidedly more limited than for US graduates. According to the physician-supply experts writing[1] in the New England Journal of Medicine, the way the US system works is that IMGs get very little specialty choice so that US seniors can have much more specialty choice.

US seniors enjoy a “selection subsidy,” the authors wrote. IMGs take the less competitive positions in primary care, and as a result, US seniors have improved chances of getting highly competitive positions in such areas as surgery. The US students wouldn’t have such a wide choice if there were just enough positions for them alone. In other words, in a zero-sum system, they would have to take a certain percentage of primary care slots or not get anything at all.

There has been a wide gap between IMGs’ specialties and those of US seniors. In the 2015 Match, 39% of US seniors chose primary care, and those who chose internal medicine often plan to subspecialize. Meanwhile, fully 67% of IMGs filled primary care spots. For many of them, it was the only way to get into the US system. In some cases, the specialties they had practiced in their home countries were different from the ones they were able to get into here.

Most IMGs seem to make the best of this lack of specialty choice and enjoy a career in their assigned specialty, but some do not. A study[14] of family physicians found that being an IMG was a key predictor of dissatisfaction with the specialty.

When many IMGs in internal medicine try to subspecialize, the choices again are limited. Fellowships in some subspecialties are less IMG-friendly than others. An analysis[15] of 2012 Match data found that although infectious diseases was the easiest subspecialty for all applicants to get into, on the basis of the ratio of applications to acceptances, it was the third hardest for IMGs. And although allergy was the sixth hardest for all applicants to get into, it was the hardest of all for IMGs.

Nephrology, on the other hand, was the second easiest for everyone and the easiest of all for IMGs. Nevertheless, nephrology wasn’t the first choice for many of the IMGs going into it. In a separate 2012 study,[16] 23% of IMG nephrologists didn’t choose the specialty, compared with 11% of US graduates

Even after training, many FIMGs again put aside what they want to do and agree to work in remote areas of the United States. Left to their own devices, FIMGs tend to gravitate to large urban areas, where they can congregate with other people from their country, but they agree to serve in remote areas because that’s the only way they can stay in America.

The J-1 visas that are issued to FIMGs during training require them to go back to their home countries for 2 years after their training is completed. Apparently most of them do go back home—after all, many of them came here just for the training. But J-1 holders can get the requirement waived if they agree to work in an underserved area in the United States for a few years in several different programs. There are a limited number of such positions, and the competition for them is often very intense.

As one might expect, working in small-town America can be quite lonely for a newly arrived foreigner. In his book My Own Country, Abraham Verghese, MD, recounts serving as a resident in Johnson City, Tennessee, where he was virtually the only person from India. He recalled going to the local bar to drink with one of his few friends, the mechanic who worked on his car. Afterward, Dr Verghese entered an infectious diseases fellowship in Boston. But interestingly, when he finally had a choice of where to practice, he decided to return to Johnson City. He turned out to be invaluable to the community, fighting the AIDS epidemic when it had just arrived in the area.

Meeting Cultural Challenges
Graduates from India are still the largest IMG group in the United States, representing 20.7% of the total, according to the AMA’s IMG Section.[17] However, there has been a decline in the number of new candidates from India and a rise in the number of USIMGs, according to a recent speech[18] by the ECFMG’s president.

Even so, FIMGs still make up the lion’s share of the American IMG population. In addition to India, the top countries of origin for FIMGs are Pakistan, China, the Philippines, Iran, and Israel, according to the AMA’s IMG Section.

When Alok A. Khorana, MD, an Indian IMG, arrived at a US residency program in 1996, it was a massive culture shock. “I had never used a pager or answered a page, never looked up labs on a computer screen, never dictated a note, never been exposed to American patients’ expectations of privacy and medical information, never dealt with discharge planning or nursing home placement or insurance issues,” he recalled in an article[19] in Health Affairs.

He had already been responsible for treating patients at his medical school in India, so his clinical experience was vastly greater than that of his US peers, but when he treated his first patient, he was stumped. She needed something for her pain, and the nurse on duty suggested Tylenol, but Dr Khorana had never heard of Tylenol. He realized then that he had many more things to learn. He easily made it through residency, but he faults his program (and most others) for failing to provide an orientation course for IMGs.

Most FIMGs also have to struggle with language. Since all of them had to pass the Spoken English Proficiency component of the USMLE, they can speak and understand English very well, but “the ability to communicate goes beyond the ability to speak and write English,” according to an opinion piece[20] published by the American College of Physicians. “Accents, slang terminology, street language, and idioms all influence the communication between physician and patients as well as hospital staff,” wrote Barbara L. Schuster, MD, a former American College of Physicians regent.

“It’s easier for people like me, because I’ve spoken English all my life, even in medical school,” Dr Ahmad says, “but I know I still have an accent.” (His English is usually quite clear, but when he said he had studied at Harvard, it sounded like he said “Howard.”) “Also, there is a different kind of English spoken here, so you have to learn the lingo,” he says.

FIMGs can take courses to improve their language skills. According to the “medical accent reduction” page[21] on the website of G.E.T. English Training in Dallas, “there is a big difference between a language barrier and an accent barrier. If you are frequently asked to repeat yourself, you are a candidate for accent reduction.”

Dr Ahmad, a dignified man of patrician bearing, became a kind of George Washington figure for IMGs in the AMA. In the late 1980s, he served on an AMA committee that planned an IMG advisory committee and became its chair when it was launched in 1989. And when it became a full-fledged AMA section in 1997, he became the section’s first chair.

For 2 or 3 years after the World Trade Center attacks on September 11, 2001, Dr Ahmad reports, it was hard for IMGs from such countries as Pakistan to get visa clearances from the US Department of State.

The Struggle to Get Promoted
IMGs have a conflicting sense of self-worth in America, says Peggy G. Chen, MD, a researcher at the RAND Corporation who has studied the IMG experience extensively. “As a doctor, you’re in a high-prestige position, but as an IMG, you may be viewed as an outsider by some of your patients and some of your colleagues,” says Dr Chen, whose own parents were highly educated immigrants.

According to a 2012 study[22] that Dr Chen led, IMGs report lower satisfaction with their careers. Whereas 82.3% of US graduates reported career satisfaction, 75.7% of IMGs did so. The study was unable to identify why this is, but some light was shed on this in an earlier anecdotal study[23] led by Dr Chen, in which several IMGs were interviewed. In that study, a family physician from Southeast Asia working at a large organization said that few IMGs reach the top, and their work is “not validated” by the organization.

Someone who has had these kinds of experiences is Bhushan Pandya, MD, chairman-elect of the AMA’s IMG Section and a gastroenterologist in Danville, Virginia. When he arrived in Danville in 1985, he was one of the first IMGs in the area, and his application for privileges at the local hospital was “delayed and delayed,” he recalls. Only with the help of a lawyer was he finally able to get on staff. He then joined the same hospital credentials committee that had balked at granting him privileges and eventually became its chair. As the new evaluator of applications for privileges, “I made sure that everyone was treated equally,” he says.

Dr Pandya’s easygoing manner and willingness to promote change from the inside no doubt helped make him popular with colleagues. He became the first IMG president of the medical staff, and currently he’s president-elect of the Medical Society of Virginia. Again, he’s the first IMG to hold the position. “It’s to the credit of the establishment that they elected me,” he says.

Like Dr Ahmad, Dr Pandya is a steadfast advocate of assimilation. When he arrived in Danville, he was told, “Everyone here has roots in Danville,” he recalls. “I may not have roots here,” he replied, “but my grandchildren will.”

Dr Pandya believes there’s less discrimination against IMGs within medicine than when Dr Ahmad formed the IMG Section two decades ago. Last year, when leaders of the section met with the AMA president, “nobody was talking about discrimination,” he says. The subjects were the usual ones for other physicians: electronic medical records, the move to the 10th edition of the International Classification of Diseases, and the new payment methodologies.

“Many of us have been able to establish ourselves in mainstream medicine,” Dr Pandya says. “After all, we represent 25% of the physician workforce.”

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References

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