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Academic Medicine:
doi: 10.1097/01.ACM.0000243353.62431.3e
Concurrent Sessions

Concurrent Sessions: Exploring Issues Relating to International Medical Graduates

Gastel, Barbara MD, MPH

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Dr. Gastel is associate professor of integrative biosciences and of humanities in medicine, Texas A&M University, College Station, Texas.

The Educational Commission for Foreign Medical Graduates (ECFMG) 50th anniversary invitational conference, “Impact of International Medical Graduates on U.S. and Global Health Care,” brought together 218 participants, representing 24 countries. These participants brought expertise in a wide range of relevant fields, including physician workforce issues, accreditation, international medical education, cross-cultural issues in medicine, and assessment of physician competence. As well as attending presentations at the conference, the participants shared their expertise and ideas in concurrent small-group sessions on the following five topics: workforce and distribution, accreditation, improving international medical education, international medical graduates (IMGs) and the challenge of acculturation, and quality of IMGs. The set of concurrent sessions was presented twice in immediate succession, allowing each participant to take part in discussing two of the five topics.

Each small-group session consisted of a brief presentation by the facilitator, followed by discussion by the other attendees. For some of the topics, the groups broke into subgroups, each of which then reported to the full group. Then at the plenary session that followed the concurrent small-group sessions, each facilitator summarized points made. It was noted that often the discussion was lively.

Presented below are overviews of the concurrent small-group sessions on the five topics. In each, a synopsis of the facilitator’s opening presentation at the small-group session is followed by a summary of points raised in discussion.

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Session on Workforce and Distribution

This session was facilitated by John R. Boulet, PhD, assistant vice president for research and evaluation, ECFMG, Philadelphia, Pennsylvania. The co-facilitators were Danette W. McKinley, PhD, research scientist, Foundation for Advancement of International Medical Education and Research (FAIMER), Philadelphia, Pennsylvania, and Richard A. Cooper, MD, professor of medicine, Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania.

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Presentation

Dr. Boulet began this concurrent session by noting that in the United States, IMGs (graduates of medical schools outside the United States and Canada) constitute approximately 25% of the physician workforce and occupy approximately 25% of residency positions. He mentioned that shortages of physicians in the United States are projected and said the recommended increase in class size at U.S. medical schools will take several years to help allay this shortage. He thus concluded that the United States will continue to depend on IMGs for a substantial time.

The rest of the presentation consisted largely of statistics on IMGs in the United States. Sources of data were ECFMG application information (regarding citizenship, medical school attended, and demographics) and the 2005 American Medical Association (AMA) Physician Masterfile (regarding practice, location, and training). Information included the following:

Of professionally active physicians in the United States, excluding individuals aged 70 and older and residents, 477,369 are graduates of U.S. or Canadian allopathic medical schools (MDs), 42,258 are graduates of osteopathic medical schools (DOs), 27,771 are IMGs who were U.S. citizens upon entering medical school (USIMGs), 120,675 are IMGs who were not U.S. citizens upon entering medical school (non-USIMGs), and 2,344 are IMGs of unknown citizenship at the time of medical school attendance.

Larger percentages of IMGs than of U.S. medical graduates occupy residency positions in internal medicine and family practice. The reverse is true for anesthesiology, obstetrics and gynecology, psychiatry, diagnostic radiology, emergency medicine, and orthopedic surgery.

Among U.S. physicians other than residents, about 80% of graduates of U.S. medical schools identify patient care as their major professional activity. The corresponding figure slightly exceeds 90% for DOs and USIMGs, and it is nearly 90% for non-USIMGs. The percentage of active physicians who are in primary care is about 35% for allopathic physicians who graduated from U.S. medical schools, somewhat more than 50% for DOs, almost 50% for USIMGs, and almost 40% for non-USIMGs.

IMGs are not evenly distributed among U.S. states. They constitute 30–40% of active physicians in New York, New Jersey, West Virginia, Illinois, and Florida. At the other extreme, they are less than 10% of active physicians in Vermont, Montana, Idaho, Wyoming, Utah, Colorado, Oregon, and Alaska. Regarding total numbers of IMGs who are active physicians: New York, Florida, and California each have more than 10,000; New Jersey, Pennsylvania, Ohio, Michigan, Illinois, and Texas each have 5,000 to 9,999. As the lower extreme, Maine, Vermont, and New Hampshire have fewer than 500 IMGs each, as do Alaska and Hawaii and a number of the less populous states in the West and upper Midwest.

Of IMGs in the United States, 157,410 have completed residencies and are involved in patient care, 30,899 are residents, 7,908 are pursuing other professional activities, 19,833 are inactive, and 14,890 are not classified.

Data also are available on where IMGs received their undergraduate medical education and on IMGs’ country of citizenship at the time of medical school. The greatest proportion of IMGs in the United States—somewhat more than 20%—attended medical school in India. The Philippines is a distant second, at about 8%. Next come Mexico, Pakistan, and the Dominican Republic. The next 10 countries in the list are Grenada, Egypt, South Korea, China, Dominica, Iran, Italy, Spain, Netherlands Antilles, and Syria. Of IMGs in the United States, slightly more than 20% were citizens of India at the time of medical school, and about 18% were U.S. citizens. Next come the Philippines, Pakistan, China, Iran, Korea, Egypt, the U.S.S.R., Syria, the United Kingdom, Cuba, Nigeria, Colombia, and Lebanon. The medical schools that have contributed the greatest numbers of IMGs are, in descending order, the Universidad Autónoma de Guadalajara (nearly 7,500 IMGs), University of Santo Tomas (about 7,000), St. George’s University (more than 5,000), Ross University (more than 4,000), and Dow Medical College (more than 3,000). Next on the list, at about 2,500 to 3,000 apiece, are the American University of the Caribbean, Far Eastern University–Nicanor Reyes Medical Foundation, University of the Philippines Manila, University of the East–Ramon Magsaysay Memorial Medical Center, and University of Damascus.

Altogether, about 12,500 IMGs in the United States are from Africa. Of these, about 35% are from Egypt, 22% from Nigeria, 15% from South Africa, 6% from Ghana, 4% from Ethiopia, 4% from Kenya, and 14% from elsewhere.

Overall, the number of ECFMG applications and the number of ECFMG certifications have been increasing since about the year 2000. Current numbers for each are about 10,000 per year.

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Discussion

Participants in this session received four questions as starting points for discussion: In planning for the U.S. health workforce, how can we best utilize IMGs? Will the projected increase in the number of U.S.-trained physicians affect overall distribution and specialization? What is the future role of U.S.-citizen IMGs? Will physician migration patterns change in the future?

During the discussion, which Dr. Boulet summarized at the plenary session, the following points emerged:

Role of nonphysician health care providers. Physician assistants, nurses, and nurse practitioners contribute to the provision of health care, and therefore workforce models should include these professionals. However, given the number of services provided by these individuals, transferring responsibilities for patient care might not appreciably resolve physician shortages.

Planning and distribution. The increase in output of U.S. medical schools must be accompanied by a corresponding increase in the number of residency positions available, especially in primary care specialties. Otherwise, IMGs could be forced out of the system, and shortages will persist.

The U.S. government could continue to use immigration law to address shortages and geographic maldistribution of physicians. Need may exist for a single type of work visa, having service requirements, for all IMGs seeking graduate medical education.

The increasing number of USIMGs applying for ECFMG certification suggests that the number of U.S. students who want to be doctors exceeds the number accepted to U.S. medical schools. It is reasonable to assume that, given increased enrollment at U.S. medical schools, many such individuals will attend medical school in the United States rather than elsewhere. This change may shift the composition of “off-shore” medical schools and of osteopathic medical schools. The quality of U.S. medical graduates could be affected as more places become available in U.S. medical schools.

The role of osteopathic physicians should not be ignored in physician workforce planning.

Cultural diversity and workforce planning. The United States has a culturally diverse patient population, and IMGs contribute helpful diversity to the physician workforce, through familiarity with patients’ cultures and native languages. If the proportion of U.S. citizens in the physician pool increases, cultural and linguistic needs of some patient groups might not be met as well as at present.

Potential changes in physician migration. Globalization of medicine could result in U.S. physicians’ migrating to other countries to pursue specialty choices or other career interests. Although currently many internationally trained physicians want to pursue graduate medical education in the United States, this might not be so in the future. Changes in the numbers of IMG s arriving could affect the U.S. physician workforce.

Brain drain. Developed nations have a responsibility to address issues of “brain drain.” Although the U.S. physician workforce has more than 150,000 active IMGs and is likely to gain more, most of these individuals come from a few countries and graduated from select medical schools. Many IMGs come from countries where the loss of health professionals has little impact on local populations. However, in some cases, especially those of African nations, emigration can profoundly impair the country’s ability to provide adequate health care.

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Session on Accreditation

This session was facilitated by Frank A. Simon, MD, director of undergraduate medical education policy and standards, AMA, Chicago, Illinois, and member, Board of Trustees, ECFMG. The co-facilitator was Marta van Zanten, research associate, FAIMER, Philadelphia, Pennsylvania.

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Presentation

Early in the presentation that opened this concurrent session, Dr. Simon differentiated accreditation from recognition. Accreditation, he stated, is a process of quality assurance. It is based on standards for process and outcomes; addresses functions, structure, and performance; and is designed to foster improvement in institutions and programs. Recognition attests to the authority to provide an educational program and grant a degree. He noted that the two terms or concepts are not clearly distinguished worldwide and, indeed, in some places are used interchangeably.

Other main points in the presentation were the following:

Accreditation entails an evaluation of education programs. The evaluation is conducted by an official authority, which may be either governmental or independent but is accountable to the government. The accreditation process uses established criteria, standards, and processes. Accreditation may be either voluntary or mandatory. It is not a system for ranking institutions.

No complete source of information exists about accrediting bodies worldwide. Thus, in many cases knowledge is not available about what information is gathered, how it is gathered, and how the information is used to reach conclusions about quality.

The Foundation for Advancement of International Medical Education and Research (FAIMER), established in 2000 by the ECFMG, is building and maintaining a database of international accrediting authorities, broadly defined. Provided for each country listed in the database is the name of the accrediting authority (or authorities) and a link to the relevant Web site, if available. The directory does not encompass all organizations with responsibilities related to approving medical schools or medical education programs.

Of the 171 countries with medical schools listed in the International Medical Education Directory, a FAIMER project, approximately 42% have accreditation authorities, 10% have no accreditation authorities, and 3% have accreditation authorities in the planning stages; for the other 45%, it is unknown whether accreditation authorities exist. The 73 countries known to have accreditation authorities include most of those with English-speaking medical schools, most with schools that attract U.S. citizens, and some others around the world. Among countries with accreditation authorities are Argentina, Australia, Canada, the Czech Republic, India, Ireland, the Netherlands, the Philippines, South Korea, and the United Kingdom. In 60% of the 73 countries, accreditation is mandatory; in 18%, it is voluntary; and in the other 22%, whether it is mandatory is unknown. Accreditation is done by a government authority in 49% of the 73 countries and by an independent entity in 45%; for the remaining 6%, it is not known whether the entity is governmental or independent.

Among the countries with no known accreditation authorities are Azerbaijan, Congo, Egypt, France, Iceland, and Zimbabwe. Some countries without accreditation authorities have few medical schools. In some places, there is a regional rather than national system of accreditation. Some countries without accreditation systems have national curricula.

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Discussion

Discussion at the session focused on several topics. The main points raised about each were as follows:

Framework for accreditation. There was universal agreement that there should be an internationally accepted framework for accreditation. The system for accreditation should evaluate both process and outcomes. Several sets of standards are needed so that there are modifications for local conditions. No one set of standards should be considered to be better than another. Standards have been developed by several entities including the World Federation for Medical Education (WFME), the Liaison Committee on Medical Education, the Institute for International Medical Education, and the Caribbean Accreditation Authority for Education in Medicine and Other Health Professions. The WFME standards use a two-tiered system with a basic level for accreditation and a quality improvement level.

Value to institutions of assessment of quality. Private medical schools need to be recognized as offering legitimate educational experiences; accreditation is less important in this regard for public medical schools. Eventually the ECFMG could require that applicants for certification be graduates of medical schools accredited by local authorities. During the discussion of this topic, the question was raised as to whether a high-quality graduate medical education could compensate for an inferior undergraduate medical education.

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Desired outcomes of an international accreditation system.

The most beneficial outcome would be improved quality of medical schools. Existence of an international accreditation system also would help prospective students to judge the quality of medical schools. In addition, by helping to ensure the quality of undergraduate medical education, such a system would reduce the need to assess prospective residents.

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International organization to “accredit the accreditors.”

Views on this matter varied. The first round of participants said such an organization should not exist, as its activities would be too far removed from the educational process to be effective. The second group, however, favored an overarching organization but noted that perhaps its efforts should be in the form of assistance and support, rather than “accreditation.” Such efforts could be initiated through either an international entity such as FAIMER or the WFME or through a regional entity such as the World Health Organization Eastern Mediterranean Region, the European Union, or the Caribbean Community.

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Unintended consequences of a rigorous system to assess quality of international medical schools.

Such a system might lead to reduction in the physician workforce if medical schools failing to meet the standards were forced to close. In addition, it might facilitate migration; on the negative side, it could contribute to brain drain, but on the positive side, it could aid in globalization. It also might stimulate collaboration between medical schools to meet the standards, thus improving medical education.

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Availability of accreditation information.

Debate exists on who should have access to data obtained in the accreditation process. Currently the barrier to accreditation for many medical schools is insufficient resources and infrastructure, not opposition to accreditation standards.

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Session on Improving International Medical Education

This session was facilitated by John J. Norcini, PhD, president and chief executive officer, FAIMER, Philadelphia, Pennsylvania. The co-facilitator was William P. Burdick, MD, MSEd, assistant vice president for education, FAIMER.

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Presentation

Dr. Norcini opened this concurrent session by asking how FAIMER could strengthen the link between its education strategy and the improvement of the health of populations. He stated FAIMER’s mission of improving medical education by developing faculty, supporting quality improvement, and informing policy and practice. He then presented the following model of faculty development: create a critical mass of medical educators; then support and stimulate growth of medical education units; thereby improve medical education; and thus improve population health.

Dr. Norcini said that FAIMER has chosen to focus on specific geographic regions in order to have more impact and to be able to assess more readily the effectiveness of its work. Its primary focus has been India and more broadly South Asia. Other areas of focus are South America and Africa.

The “crown jewel” of FAIMER’s activities, Dr. Norcini noted, is the FAIMER Institute, a two-year fellowship program for international medical faculty. Started in 2001, the institute provides 16 fellowships per year, mainly to midlevel faculty members. Each fellow must do a project that has support of his or her institution. The project should lead to improvement of community health through enhancement of medical education.

In their first year as FAIMER fellows, faculty members spend three weeks in the United States, receiving instruction on basic topics and meeting the second-year fellows who will serve as their mentors. They then have 11 months of distance learning, during which they participate in online discussions and submit progress reports on their projects. In the second year, they spend two weeks in the United States, learning about advanced topics and meeting the new fellows. The fellowship concludes with another 11 months of distance learning, during which they work with those they are mentoring and focus on publishing their own work.

The FAIMER Institute curriculum, which is based on needs assessment, focuses on educational methods and on leadership and management. The major aspects of educational methods addressed are large- and small-group teaching, including problem-based learning; use of educational technology; and assessment. Main topics within leadership and management are project management, program evaluation, change theory, and conflict management. The FAIMER Institute receives ongoing external evaluation through the University of New Mexico.

FAIMER also has been developing Regional Institutes. In India, two Regional Institutes—one at Seth GS (Gordhandas Sunderdas) Medical College in Mumbai, and one at Christian Medical College in Ludhiana—have been co-created with local FAIMER fellows and are now under way. These Regional Institutes, which are modeled after the FAIMER Institute, are locally relevant and cost-efficient, and they encourage and sustain development of local networks of educators. Regional Institutes elsewhere in India and in Brazil and South Africa are being planned.

A participant in the session asked for examples of projects done by FAIMER Institute fellows. The examples given were projects on the following topics: problem-based learning, the assessment system, and training community health workers regarding human immunodeficiency virus infection. It was noted that the funding for the projects must come from the local medical school.

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Discussion

After the presentation, participants in the concurrent session met in several subgroups. First, members of pairs within each subgroup were to interview each other about the question “What have been your best experiences with linkage between a faculty development program and community health and why were they successful?” (Members without experiences in this realm discussed related experiences.) Then the members within each subgroup came together to identify common themes of successful linkages and to consider how they could be applied to FAIMER’s education strategy. Finally, a representative of each subgroup reported on main points raised.

At the plenary session, Dr. Norcini briefly described the FAIMER Institute and Regional Institutes. He then summarized suggestions made by subgroups at both sessions with regard to helping the FAIMER Institute link improvements in medical education to improvements in community health. These suggestions fell into four groups:

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Include curriculum that promotes establishment of such links.

Add a public health component to the institute curriculum. Provide opportunity for fellows to earn an MPH degree or a certificate in public health.

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Choose and nurture fellows in ways that foster such links.

Recruit as fellows faculty members who are interested in and committed to community health. Create a critical mass to influence leadership and change institutional culture. Sustain and support a community of educators through repeated exposure and reinforcement, and track individuals; provide Web-based tools for communication, and supply ongoing financial resources. Consider accepting teams of participants; include not only physicians but also other health professionals, and have team-based community projects.

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Require FAIMER institute projects to focus on some aspect of community health.

Ensure that topics for projects emanate from the needs of the community and that the community is involved in developing solutions. Establish partnerships between medical schools and communities. Within the projects, educate and involve lay health workers. Focus curriculum on diseases of the community. Include projects providing patient education and community education. Also include preventive health projects. Conduct training programs in underserved areas. Assess community needs to determine education needs; emphasize “socioresponsiveness,” and focus on prevention and on data collection. Encourage sustainability of projects, for example by endowing prestige on the programs and by establishing linkages to governmental and other resources.

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Encourage projects that require students to work in communities.

Favor projects providing direct service to the community, through “service learning” or “experiential learning”; in doing so, recognize the power of learning through responsibility, give students tools that allow them to face unfamiliar cultures, and increase students’ awareness of service. Consider student-led initiatives. Give academic credit for service.

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Session on International Medical Graduates and the Challenge of Acculturation

This session was facilitated by Gerald P. Whelan, MD, director, Acculturation Program, ECFMG, Philadelphia, Pennsylvania. The co-facilitator was Eleanor M. Fitzpatrick, MA, manager, Exchange Visitor Sponsorship Program, ECFMG.

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Presentation

Dr. Whelan began this concurrent session by defining acculturation as “helping people from one culture to understand, become comfortable [with], and work and function effectively in another culture.” He then posed the question “What’s a culture?” and presented the following points from cross-cultural psychologist Harry C. Triandis, PhD: A culture consists of the shared attitudes, beliefs, expectations, norms, and values found among people with a common language, history, and geographical region. It includes items that have helped the group adjust to its environment. It is passed on from one generation to the next.

In the context of IMGs, Dr. Whelan then defined acculturation as helping doctors from various cultures deal sensitively and effectively with typical American people. He compared this concept with that of cultural competence, in which typical American doctors learn to deal sensitively and effectively with people from various cultures. He then observed that, of course, there are no such things as typical American doctors and typical American people—or typical doctors and other people of other cultures.

Whelan then identified three areas that IMGs had identified as being especially challenging. These areas were language and other aspects of communication, medical culture, and popular culture.

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Discussion

After the presentation, those at the session were broken into three subgroups. Each subgroup was assigned one of the three areas: language and communication, medical culture, or popular culture. For the assigned area, the subgroup was to identify major issues, note potential pitfalls, propose strategies for resolution, and state obstacles to resolution. Then for each of the three subgroups, a representative presented a summary to the entire group attending the session.

In presenting an overview at the plenary session, Dr. Whelan again noted the distinct but overlapping concepts of cultural competence and acculturation. He then listed challenges noted in each of the three areas discussed. He concluded by making some general points.

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Language and other aspects of communication.

For IMGs, sources of difficulty with regard to language and other aspects of communication can include idioms, “medicalese” (medical slang) and medical humor, nonverbal communication (for example, norms regarding personal space and eye contact), regional and ethnic dialects, and individuals who speak neither English nor another language the IMG knows.

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Medical culture.

With regard to medical culture, a number of areas present challenges to IMGs: In part because patient autonomy is greater in the United States than in many other countries, cross-cultural issues can arise regarding the patient–physician relationship. Also, medicine is less hierarchical in the United States than in much of the rest of the world; thus, for example, IMGs often must adjust to the expectation that they volunteer their ideas on rounds and on conferences. Other areas posing cross-cultural issues include the role of the patient’s family, the prominence of multidisciplinary health care teams, confidentiality (including items related to the Health Insurance Portability and Accountability Act, or HIPAA), the importance of medical records and other documentation, and legal considerations. In addition, differences in medical culture can be encountered from specialty to specialty.

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Popular culture.

Challenges that IMGs face regarding popular culture include those relating to survival skills (for example, obtaining a driver’s license, credit cards, and housing), participation in popular conversation (for instance, regarding politics and local sports teams), and regional variations in American culture. In addition, it was noted that IMGs can face adjustments because of leaving home and because of losing status (for example, when IMGs with seniority elsewhere must repeat residencies in order to practice in the United States). Cultural issues also arise regarding family members who are accompanying IMGs.

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Other points.

Acculturation must be a two-way street. Thus, resources relating to acculturation are needed not only for IMGs but also for faculty members who teach them. The types of issues faced are internationally generic, confronting physicians emigrating from one culture to another whatever those cultures may be. The challenges are only now being addressed, but they are critical given the global migration of physicians.

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Session on Quality of International Medical Graduates

This session was facilitated by Stephen H. Miller, MD, MPH, president and chief executive officer, American Board of Medical Specialties, Evanston, Illinois, and member, Board of Trustees, ECFMG. The co-facilitator was Stephen S. Seeling, JD, vice president for operations, ECFMG, Philadelphia, Pennsylvania.

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Presentation

In introducing this concurrent session, Dr. Miller reported that IMGs constitute about 25% of the U.S. physician workforce. He also noted that there is a projected shortage of physicians in the United States and that to overcome this shortage it has been recommended that class size at U.S. medical schools increase. In addition, he said that increasing numbers of USIMGs have been applying for ECFMG certification. He raised the issues of how USIMGs and non-USIMGs differ and how to assess the quality of individuals, and he asked participants to consider (1) what data, other than those he would be presenting, would aid in assessing the quality of IMGs; and (2) what elements, if any, of an undergraduate medical education can increase overall quality of IMGs.

Dr. Miller then presented the following information:

Quality can be assessed through both cognitive measures and performance ratings. Cognitive measures include the United States Medical Licensing Examination (USMLE) and board certification examinations. Performance ratings include the USMLE Step 2 Clinical Skills examination, evaluations by directors of residency programs, ratings by peers, clinical performance evaluations in maintenance of certification, and maintenance of licensure.

ECFMG certification is designed to provide evidence that graduates of medical schools outside the United States and Canada have met the necessary standards to enter residency in the United States. Subsequent indicators of quality include acceptance to residency, performance on Step 3 of the USMLE, and achievement of board certification.

To help answer questions about quality of IMGs, application data were obtained from the ECFMG, and pass rates were obtained for the USMLE. The application data included year of first examination; whether, and if so when, certification was achieved; whether a residency was obtained; and whether the individual is listed in the AMA Physician Masterfile.

The number of USIMGs seeking certification has increased substantially since the early 1990s. However, especially since about 1999, the percentage of USIMGs passing Step 1 of the USMLE has been much lower than that for examinees from U.S. medical schools and also lower than that for non-USIMGs. Whereas the pass rate for those from U.S. medical schools has been 90% or above and that for non-USIMGs has been 70% or slightly less, that for USIMGs has ranged from about 50% to 60%. Whereas from about 1995 to 2000 similar percentages of USIMGs and non-USIMGs passed Step 2 Clinical Knowledge of the USMLE, scores have diverged since then. For the most recent three years for which scores are available, pass rates exceeded 90% for examinees from U.S. medical schools, were 80% or slightly lower for non-USIMGs, and were approximately 65% for USIMGs. However, pass rates for Step 2 Clinical Skills since 2000 have been somewhat higher for USIMGs than for non-USIMGs, with pass rates for USIMGs ranging from about 85% to 90% and pass rates for non-USIMGs hovering at 80% or slightly above. Over the years, greater proportions of USIMGs than non-USIMGs have been accepted to residency. Pass rates for USMLE Step 3 since the mid 1990s have consistently exceeded 95% for graduates of U.S. medical schools; they have ranged from about 70% to 80% for USIMGs and from slightly above 50% to about 75% for non-USIMGs. Whereas until recently Step 3 pass rates for USIMGs consistently exceeded those for non-USIMGs, it appears that the rates may now be converging.

It seems that among IMGs who took their first ECFMG examination at least several years ago and thus are likely to have completed their training, the percentage of USIMGs represented in the AMA Physician Masterfile has tended to exceed somewhat the percentages of non-USIMGs represented. Higher proportions of non-USIMGs than of USIMGs and U.S. medical school graduates work in Health Professional Shortage Areas.

Distribution among specialty areas differs between U.S. medical school graduates and IMGs. The difference appears most striking with regard to internal medicine, the self-designated specialty of 35.9% of USIMGs and 33.3% of non-US IMGs but of 13.4% of U.S. medical school graduates. Of physicians with board certification, internal medicine is the most common specialty for all three groups; however, for U.S. medical graduates, internal medicine is the specialty of 24.0% of board-certified physicians, whereas the corresponding figures are 56.2% for non-USIMGs and 44.3% for USIMGs. In all, 26.8% of board-certified USIMGs, 13.3% of board-certified U.S. medical graduates, and 9.4% of board-certified non-USIMGs are certified in family practice. The percentages for the three groups for pediatrics all fall in the range of 9.3% to 11.0%.

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Discussion

At the end of the presentation, the following themes were identified for discussion: quality versus quantity, fulfillment of needs for primary care, and provision of care to medically underserved areas. Other topics receiving considerable discussion included additional data desired and quality of USIMGs.

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Additional data desired.

Although much data had been presented, participants repeatedly expressed the wish for more; the types of data that were requested differed according to the participant’s background, for example as a residency program director or a member of a state licensing board. Among items sought were information on disciplinary actions, malpractice, school-specific examination performance, predictors based on behavior during medical school, and longitudinal performance. There also was considerable interest in knowing more about the quality of the medical school from which the IMG came; aspects about which information was sought included curriculum, standards, and oversight.

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Quality of USIMGs.

Participants in the session considered possible reasons for the differences in performance of USIMGs and non-USIMGs. There was extensive discussion of the pool of U.S. citizens attending international medical schools. Questions were raised as to whether most of these individuals had applied to U.S. medical schools, what their backgrounds were, and whether information existed about whether members of this group generally had the intellectual and other attributes needed to be a physician in the United States. There were calls for more data about the international medical schools that graduate many USIMGs and calls for information about whether credible processes of accreditation or review are available in the Caribbean. A number of participants discussed the clinical rotations of U.S. students attending medical schools in the Caribbean. It was noted that almost all of these students do their clinical rotations “off island,” often in the United States or United Kingdom. Concerns were expressed that these rotations were occurring in hospitals unsuitable for such educational experience. A representative of a Caribbean medical school argued fervently that the education of USIMGs could be improved if suitable hospitals in the United States were more accessible to USIMGs seeking appropriate clinical rotations.

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Other points.

Also during the discussion, the issue was raised of whether projections of physician need are based on correct premises or whether, for example, physicians should be used more efficiently and other health care providers should take larger roles. The question also was asked whether data gathered in the accreditation of international medical schools could be used for purposes such as those addressed in this session. The need was emphasized for better tracking of the performance of both IMGs and U.S. medical graduates after licensure and certification. With regard to undergraduate medical education, there was broad agreement that more attention should be devoted to core elements that would increase the quality of graduates.

In ending his summary, Dr. Miller reiterated the need for more information, including better tracking. He also called for developing means of more comprehensive evaluation, especially those moving beyond the cognitive realm.

Barbara Gastel, MD, MPH

Dr. Gastel is associate professor of integrative biosciences and of humanities in medicine, Texas A&M University, College Station, Texas.

© 2006 Association of American Medical Colleges

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