Rao, Nyapati R. MD, MS; Rao, Uttam K.; Cooper, Richard A. MD
Dr. Rao is professor of clinical psychiatry, Department of Psychiatry, State University of New York, Downstate Medical Center, New York, New York.
Mr. Rao is an undergraduate student, Columbia University, New York, New York.
Dr. Cooper is professor of medicine, Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania.
Correspondence should be addressed to Dr. Cooper, Leonard Davis Institute of Health Economics, University of Pennsylvania, 3641 Locust Walk, Suite 314, Philadelphia, PA 19104-6218; telephone: (215) 746-3173; e-mail: 〈firstname.lastname@example.org〉.
Purpose: To assess the attitudes of medical students in India about participating in graduate medical education in the United States and other countries and in subsequent clinical practice in those countries.
Method: A total of 240 students who were attending their final year at two medical schools in Bangalore, India, were surveyed during 2004. Surveys were completed by 166 (69%) of the students.
Results: Among the responding students, 98 (59%) thought of leaving India for further training abroad. Of those who wished to leave, 41 (42%) preferred the United States, 42 (43%) preferred the United Kingdom, and 9 (9%) preferred Canada, Australia or New Zealand. Only two students preferred the Middle East. Most who favored training in the United States indicated that they intended to remain after training, whereas fewer than 20% of those who favored training in the United Kingdom had such intentions. While more than 60% perceived greater professional opportunities in the United States than in India, approximately 75% were concerned that the United States had become less welcoming after the terrorist attacks of 9/11, and similar numbers were concerned about the examination administered by the Educational Commission on Foreign Medical Graduates. Conversely, the majority of respondents felt that opportunities for physicians in India were improving.
Conclusions: While optimism about future medical careers in India is increasing, the interest of Indian medical students in training and subsequently practicing in the United States remains high.
For more than 50 years, the United States has relied on foreign-born graduates of foreign medical schools to supplement the output of its own medical education system. During the decade from 1995 to 2004, approximately 4,400 foreign-born international medical graduates (F-IMGs) entered the United States annually; 1,000–1,200 of these were from India.1,2 These Indian physicians represented almost 5% of all Indian medical graduates during approximately the same period of time.3,4
As the United States encounters what is likely to be a prolonged period of physician shortages,5–8 and as the prospects of increasing the output of residency programs inevitably are considered, one question that faces policymakers is whether the high level of interest that Indian medical graduates have had in training and subsequently practicing in the United States will persist. A number of factors might be expected to blunt that level of interest. These include the September 11th attacks and the consequent tightening of immigration laws, the introduction of the Clinical Skills Assessment (CSA) examination by the Educational Council for Foreign Medical Graduates (ECFMG), and the impact of global economic development on the economy and health care system of India.9–11 On the other hand, the continued expansion of the U.S. health care system combined with the evolving physician shortage in the United States might be expected to increase this level of interest.
In 1998, a survey of students at two Indian medical schools found that 56% had considered further training in the United States and that 22% had definite plans to do so.12 In the present article, we describe the results of a similar survey that we conducted in 2004.
The survey instrument consisted of a series of questions to elicit demographic information about the students, their performance in medical school, their main sources of financial support, and their immigration plans. Questions were also included to assess their cultural attitudes towards India, the United States, and various other countries. Questionnaires were in English, the language of instruction in Indian medical schools.
Two medical schools whose students were surveyed in 199812 were the sites of our survey. Both schools are located in the south Indian city of Bangalore in the state of Karnataka. One of the two schools (Bangalore Medical College) is state-supported, and the other (MS Ramiah Medical College) is a private for-profit school. Admission to both is determined by students’ performance on an entrance examination similar to the Medical College Admission Test given in the United States. Tuition at Ramiah is higher than at Bangalore Medical College. Among the students at Ramiah were several who were U.S. citizens.
Participation in the survey was offered to all the students at both schools during their final year of medical studies. Questionnaires were administered to the 150 students in Bangalore by the class secretary over a two-week period and to the 90 students in Ramiah by a faculty member during a lecture class supplemented by follow-up contacts.
Demographics and specialty preferences
The response rate was 76% at Bangalore and 58% at Ramiah, making a combined rate of 69% (166/240). (All percentages given in this report were rounded to the nearest whole number.) Of those responding, 156 (94%) were ages 20–24, 113 (68%) were men, 154 (93%) were single, 141 (85%) said their religion was Hinduism, 75 (45%) spoke Kannada as their mother tongue, 128 (77%) were middle class, and 143 (86%) said their families were the source of support for their medical education. Because Indian medical schools do not require four years of college, most students were younger than 24 years at graduation, whereas the mean age of graduating seniors in the United States is almost 28 years.13 Compared with U.S. students, a higher percentage of Indian students were men, and unlike their counterparts in the United States, most students were single, reflecting the different social structures that exist in India, where marriage is often arranged by families and where students commonly postpone marriage until they have completed their education to the satisfaction of their families, who are generally the main source of financial support for medical education. This support, combined with the fact that tuition in India is less than in the United States, left Indian medical students with almost no educational debt. Fifty-one (31%) of the responding students expressed an interest in medicine and its subspecialties, 46 (28%) in surgery and its subspecialties, and 25 (15%) in pediatrics.
Many of the findings about the attitudes of the 166 responding Indian medical students about cultural and immigration matters are displayed in Table 1. Among these students, 98 (59%) thought of leaving India for further training abroad (see also Figure 1), and, of those who wished to leave, 41 (42%) preferred the United States, compared with 56% in 199812. An additional 42 (43%) preferred the United Kingdom, 4 (4%) Canada, and 5 (5%) Australia and New Zealand. Only 2 (2%) preferred the Middle East. While approximately half of the responding students indicated that that they would avoid Middle Eastern countries because of those countries’ militant Islamic attitudes, an equal, number believed that there are better opportunities for Indian physicians in Middle Eastern countries than in Western countries.
Most of the students who favored training in the United States indicated that they intended to remain in the United States after training. In contrast, fewer than 20% of those who favored training in the United Kingdom perceived that country as a long-term destination. Rather, most planned to return to India, taking advantage of the similarities in training and certification in the United Kingdom and India, which stem from India’s prior colonial relationship with Britain.
The desire to remain outside of India after training was stronger among women than among men. Among both men and women, the most common reason given for remaining abroad was greater financial opportunity. Conversely, the most common reason for returning to India after training was to reunite with family.
Attitudes toward the United States
Students held both positive and negative opinions about the United States (Figure 2). More than 60% agreed that there are greater opportunities for financial success in the United States; two-thirds preferred the individuality and autonomy that exist in the United States; and similar numbers indicated that they liked the professionalism and shared responsibility between physicians and other health care professionals that is typical of the U.S. health system, although half thought that working under managed care is too stressful. However, approximately 75% were concerned that immigration laws make entry into the United States difficult for Indian medical students and that the United States has become less welcoming since the terrorist attacks of 9/11. Half of those responding expressed concern that recent changes in the ECFMG examination may hinder entry of IMGs, and almost three-fourths were concerned that the CSA examination is prohibitively expensive.
The opinions of Indian students about U.S. social norms were not as strongly positive as their views of professional opportunities. For example, 91 (55%) of those responding felt that people in the U.S. are too self-centered, exploitative, and uncaring; and 106 (64%) felt that the elderly are not well cared for. Ambivalence was expressed regarding the future of IMGs in the United States, with 46 (28%) agreeing with the statement that there is no future in U.S. medicine for IMGs, 56 (34%) disagreeing, and 43 (26%) indicating that they were unsure. Finally, 104 (63%) felt that the United States is not the only place where scientific medicine could be practiced, and only 60 (36%) felt that it was worth leaving India to live in the United States. Indeed, half felt that the United Kingdom, Australia, and Canada are more hospitable destinations than the United States.
Attitudes toward India
The vast majority (136, or 82%) of the responding students felt that the health care system in India has improved in recent years, and 103 (62%) were optimistic about the impact of recent economic changes on their future in India. Although 85 (51%) believed that Indian medicine remains mired in corruption and nepotism and 95 (57%) felt stifled by the caste structure in India, 80 (48%) disagreed with the statement that only the rich can succeed in India, and 129 (78%) preferred the family values that exist in India.
This survey sampled the attitudes of Indian medical students at two schools in a prosperous province of India. It is impossible to know whether these responses are representative of the almost 25,000 medical students who graduate from more than 200 medical schools located throughout India. However, the picture that emerges from this somewhat limited study is one of an increasing degree of optimism about future opportunities in India, although those feelings were not strong enough to neutralize the attraction of postgraduate training and possible immigration to various foreign countries. The strongest draw was toward the United States, although interest in the United States was less than had been observed in a similar survey in 1998, possibly relating to perceptions that the United States has become less hospitable to immigration following 9/11 or concerns about changes in the ECFMG examination. Students also expressed negative opinions about the culture of the United States, apparently reflecting differences between the group-oriented culture of India and the individualism of U.S. culture. Nonetheless, many Indian students wish to immigrate to the United States, and this was true somewhat more frequently for women than men. The presence of extended Indian families in the United States may be a facilitating factor, particularly for women students, who often find their mates through the institution of arranged marriage with Indian men who have settled in the United States. On the other hand, the expectation that male Indian medical students will support their parents in retirement might underlie the greater frequency with which they plan to return to India.
Other differences from the findings of the 1998 survey were the emergence of Australia and New Zealand as favored destinations for a small number of students and the even smaller number who were attracted to oil-rich Middle Eastern countries.
What do these findings mean for the future immigration of Indian medical students to the United States as the shortage of physicians in the United States continues to deepen? The combination of growing professional opportunities in India coupled with increasing barriers to entry to the United States suggest that Indian students may remain in India or return to India more frequently. Nonetheless, the level of interest in the United States is high, and India remains a large potential source of physicians for the future.
1 Boulet JR, director, Tracking and Research, Foundation for Advancement of Medical Education and Research, the Educational Commission on Foreign Medical Graduates (ECFMG). Personal communication, January 2005.
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