International Medical Graduates Critical to US Healthcare, Expert Says

Ricki Lewis, PhD

March 06, 2017

International medical graduates (IMGs) account for one quarter of all physicians in the United States, and blocking entry of IMGs from certain countries would cause severe repercussions, according to a March 7 commentary in Annals of Internal Medicine.

Intense debate about the issue continues despite the February 9 US Circuit Court of Appeals' denial of the Trump administration's challenge to suspension of the travel ban.

William W. Pinsky, MD, president and CEO of the Educational Commission for Foreign Medical Graduates (ECFMG), explains the intense vetting criteria that IMGs face and the negative impact on healthcare in the United States should efforts to restrict their entry resume.

Executive Order 13769, issued late on January 27, 2017, restricted entry of citizens from seven countries with large Muslim populations, plunging US airports into immediate chaos. The timing could not have been worse for IMGs applying to the National Resident Matching Program ("the Match") for the upcoming February 22 deadline.

"Residency directors might have had a great level of comfort with certain international graduates from the particular countries but didn't know if the students could get in. So the 294 applicants to the Match from the seven Muslim-majority countries from Trump's original executive order were in total limbo," Andrew Gurman, MD, president of the American Medical Association (AMA), told Medscape Medical News.

On February 3, a report in the BMJ from researchers at the TH Chan School of Public Health, Harvard University, Boston, Massachusetts, underscored the value of IMGs. They found that hospitalized Medicare beneficiaries under the care of internists who graduated from medical school outside the United States had lower 30-day mortality compared with patients cared for by graduates of US medical schools.

According to the AMA Physician Masterfile, in 2016 about 25% of US physicians graduated from medical school outside the United States (206,030 of 897,783), disproportionately serving in internal medicine. More than 10,000 of them graduated from medical schools in the seven countries (Iran, Iraq, Libya, Sudan, Somalia, Syria, and Yemen) named in the travel ban.

Reaction from the medical education community to the Executive Order was swift. Thomas J. Nasca, MD, CEO of the Accreditation Council for Graduate Medical Education, issued a statement about the approximately 1800 physicians currently in residency and fellowship programs from the seven countries: "These physicians are providing much needed medical care to a conservatively estimated 900,000 patients in urban, suburban, and rural communities across the country annually. They…are a valued and welcomed group of colleagues."

Dr Pinsky summarizes the rigorous vetting process for IMGs, which takes on average 3 years. The ECFMG certifies IMGs to be eligible to enter graduate medical education programs in the United States. The process includes primary source verification of medical school credentials, as well as passing the first two parts of the US Medical Licensing Examination. Only 60% of those who begin the process complete it.

Yet even ECFMG certification doesn't guarantee a match. "The ECFMG certification process, combined with the competitive nature of residency selection and strict state licensure rules, ensures that only high-quality, carefully screened IMGs enter the U.S. workforce," Dr Pinsky writes.

ECFMG is also charged with sponsoring IMGs for a J-1 visa. The J-1 is an "exchange visitor program" in which the holder agrees to return to their home country for 2 years to transmit knowledge gained in the United States. The 15 categories of J-1 visa holders include au pairs, researchers, high school students, teachers, and "alien physicians."

If an IMG agrees to provide care in an underserved geographical area of the United States, the return-home rule may be waived, Dr Gurman told Medscape Medical News. "The J-1 visa program provides an incentive and a pathway for international medical graduates to go to underserved communities. A lot of people like it and stay there. So for many communities — urban and rural — they are the medical system," he added.

Dr Pinsky warns that the restrictions on immigration imposed by Executive Order 13769, or some future version of it, could make pursuing graduate medical training in the United States less desirable than in more welcoming nations. In 2016, ECFMG certified IMGs from 154 countries. "Because the U.S. patient population is becoming more heterogeneous, having a diverse provider workforce is logical.... In addition to providing high-quality care, IMGs add much-needed diversity to the U.S. physician workforce," he writes. IMGs also tend to take positions that US-trained physicians do not, he observes.

If the proportion of IMGs decreases in the future and US graduates continue to choose not to practice in underserved areas, patient care may suffer, Dr Pinsky concludes. Others agree.

"The American health care system has benefited greatly from the contributions of international medical graduates. Preventing thoroughly vetted and qualified physicians from practicing in the United States will limit access to quality care, particularly in rural and underserved communities," Humayun J Chaudhry, DO, president and CEO of the Federation of State Medical Boards, told Medscape Medical News.

Added Dr Gurman, "International medical graduates account for 27% of all physicians and 31% of primary care physicians in the [United States]. So roughly a third of primary care in this country relies on international medical graduates. That is the potential implication of an executive order to change the J-1 visa."

The author and commentators have disclosed no relevant financial relationships.

Ann Intern Med. Published online March 7, 2017. Abstract

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