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

Leigh Page

Disclosures

February 03, 2016

In This Article

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.

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