Where Do International Medical Graduates Fit in the US Healthcare Picture?

Leigh Page

Disclosures

February 03, 2016

In This Article

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.

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