COVID-19 Death Toll Higher for International Medical Graduates

Laird Harrison

June 11, 2021

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Graduates of international medical schools died from COVID-19 in disproportionate numbers in the United States in 2020, researchers report.

Dr Abraham Verghese

"I've always felt that international medical graduates [IMGs] in America are largely invisible," said senior author Abraham Verghese, MD, MFA, an infectious disease specialist at Stanford University, in Palo Alto, California. "Everyone is aware that there are foreign doctors, but very few are aware of how many there are and also how vital they are to providing healthcare in America."

IMGs made up 25% of all US physicians in 2020 but accounted for 45% of those whose deaths had been attributed to COVID-19 through November 23, 2020, Deendayal Dinakarpandian, MD, PhD, clinical associate professor of medicine at Stanford University, and colleagues report in JAMA Network Open.

IMGs are more likely to work in places where the incidence of COVID-19 is high and in facilities with fewer resources, Verghese told Medscape Medical News. "So, it's not surprising that they were on the front lines when this thing came along," he said.

To see whether their vulnerability affected their risk for death, Dinakarpandian and colleagues collected data from November 23, 2020, from three sources of information regarding deaths among physicians: MedPage Today, which used investigative and voluntary reporting; Medscape, which used voluntary reporting of verifiable information; and a collaboration of The Guardian and Kaiser Health News, which used investigative reporting.

The Medscape project was launched on April 1, 2020. The MedPage Today and The Guardian/Kaiser Health News projects were launched on April 8, 2020.

Verghese and colleagues researched obituaries and news articles referenced by the three projects to verify their data. They used DocInfo to ascertain the deceased physicians' medical schools.

After eliminating duplications from the lists, the researchers counted 132 physician deaths in 28 states. Of these, 59 physicians had graduated from medical schools outside the United States, a death toll 1.8 times higher than the proportion of IMGs among US physicians (95% CI, 1.52 – 2.21; P < .001).

New York, New Jersey, and Florida accounted for 66% of the deaths among IMGs but for only 45% of the deaths among US medical school graduates.

Within each state, the proportion of IMGs among deceased physicians was not statistically different from their proportion among physicians in those states, with the exception of New York.

Two thirds of the physicians' deaths occurred in states where IMGs make up a larger proportion of physicians than in the nation as a whole. In these states, the incidence of COVID-19 was high at the start of the pandemic.

In New York, IMGs accounted for 60% of physician deaths, which was 1.62 times higher (95% CI, 1.26 – 2.09; P = .005) than the 37% among New York physicians overall.

Physicians who were trained abroad frequently can't get into the most prestigious residency programs or into the highest paid specialties and are more likely to serve in primary care, Verghese said. Overall, 60% of the physicians who died of COVID-19 worked in primary care.

IMGs often staff hospitals serving low-income communities and communities of color, which were hardest hit by the pandemic and where personal protective equipment was hard to obtain, said Verghese.

In addition to these risks, IMGs sometimes endure racism, said Verghese, who obtained his medical degree at Madras Medical College, in Chennai, India. "We've actually seen in the COVID era, in keeping with the sort of political tone that was set in Washington, that there's been a lot more abuses of both foreign physicians and foreign looking physicians — even if they're not foreign trained — and nurses by patients who have been given license. And I want to acknowledge the heroism of all these physicians."

The study was partially funded by the Presence Center at the Stanford School of Medicine and Department of Medicine. Verghese is a regular contributor to Medscape. He served on the advisory board for Gilead Sciences, Inc, serves as a speaker or a member of a speakers bureau for Leigh Bureau, and receives royalties from Penguin Random House and Simon & Schuster.

JAMA Netw Open. Published online June 11, 2021. Full text

Laird Harrison writes about science, health, and culture. His work has appeared in magazines, newspapers , and online publications. He is at work on a novel about alternate realities in physics. Harrison has taught writing at San Francisco State University, UC Berkeley Extension and the Writers Grotto. Visit him at or follow him on Twitter: @LairdH.

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