Cohen, Jordan J. MD
At 25% of the nation’s physician workforce,1 it is obvious that international medical graduates (IMGs) contribute significantly to the U.S. health care system. Beyond their sheer numbers, however, IMGs have played critically important roles, both in aggregate and as individuals. By choosing to pursue specialties less attractive to U.S. medical graduates (USMGs), IMGs have filled important gaps that otherwise would have seriously compromised the effectiveness of the U.S. health care system. Moreover, individual IMGs have made notable contributions to the improvement of clinical practice, to biomedical and health services research, and to medical education, as evidenced by appointment to high-level positions in both academe and the federal government and by election to prestigious scientific and research organizations.
The Educational Commission for Foreign Medical Graduates (ECFMG) can take justifiable pride in the important contributions IMGs have made and in their undeniably positive impact on U.S. health care. Although its fundamental purpose is to protect the American public by ensuring that IMGs entering residency programs meet acceptable standards for rendering patient care under supervision, the ECFMG has, through its certification process, enabled the best and brightest medical students from other nations to come to America to participate in all aspects of our health care enterprise.
It seems especially appropriate, therefore, as ECFMG celebrates its golden anniversary, to delve in some detail into the many contributions IMGs have made to U.S. health care. Following a brief overview of the ECFMG’s role in the certification process, I will examine the growth in number of IMGs and discuss their distribution, both geographically and in terms of specialty choice. By way of illustration, I will highlight the contributions of several especially renowned IMGs to medical education, to medical research, and to clinical practice. After a brief discussion of concerns raised by the global migration of physicians, I will conclude by predicting that the ECFMG will continue to play a vital role long into the future.
The ECFMG and IMGs
Like other foreign-born individuals who aspire to work in the United States, IMGs seek entry for many reasons: the chance to practice within a resource-rich environment; the wealth of opportunities to practice, to teach, or to do medical research; the haven afforded by America’s commitment to protect individual and intellectual freedoms; and, in many cases, the chance to escape poverty and/or chaotic circumstances at home. According to a recent report by the World Health Organization, health care workers in many other parts of the globe “face daunting work environments—poverty-level wages, unsupportive management, insufficient social recognition, and weak career development” causing them to “seek opportunities and job security in dynamic health labour markets that are part of the global political economy.”2
Among these dynamic health labor markets, the United States requires its physicians to meet what are arguably the world’s most exacting standards of professional competence. Americans have long been accustomed to a high level of medical care provided by doctors who have graduated from accredited U.S. medical schools. Given that few IMGs hoping to train and possibly practice in the United States are graduates of comparably accredited schools, some mechanism was deemed necessary to assure graduate medical education program directors (and the American public) that foreign-educated physicians were as prepared to begin postgraduate training as are their U.S.-educated counterparts.
Enter the ECFMG. The ECFMG was established in 1956 primarily to address this need for assuring “the readiness of international medical graduates for entry to graduate medical education and health care systems in the United States through an evaluation of their qualifications.”3
IMGs and U.S. Health Care
For the past 50 years, the ECFMG has provided virtually the only “gateway” through which IMGs have entered the United States from medical schools across the globe. In the past 25 years alone, the ECFMG has issued certificates to students from 170 countries.4 Today, IMGs can be found practicing in every U.S. state and in every medical specialty.1
Growth and distribution
From 1975 to 2005, the number of IMGs (both active physicians and residents in training) in the United States increased from 78,717 to 204,472.1 Today, more than one quarter of IMGs in the United States are graduates of medical schools in India (18%) or the Philippines (9%) (E. Salsberg, MPA, personal communication, August 2006).
The vast majority of professionally active IMGs, like their USMG counterparts, are engaged in direct patient care. Although precise estimates are not available, somewhat smaller percentages of IMGs than USMGs appear to be engaged primarily in research, medical education, or medical administration. Nevertheless, their contributions to academic medicine are significant. Among full-time MD faculty at U.S. medical schools, 17% are IMGs.5 Among the 1,941 U.S. medical school department chairs with medical degrees, nearly 11% are IMGs; more specifically, some 17% of department chairs in the basic sciences and close to 10% of department chairs in the clinical sciences are IMGs.6
IMGs have increasingly filled residency and fellowship positions in specialties that USMGs find less attractive. A recent study by Boulet et al. found that the number of U.S. students matching to residencies in primary care specialties “peaked at 53.2% in 1998 and declined to 44.2% in 2002”; the number of IMGs training in the associated specialties rose over this period, suggesting that IMGs “were filling gaps left vacant by U.S. medical students.”4 The percentage of family practice residents who are IMGs has increased substantially, from approximately 10% in 1980 to 35% in 2004.7,8 This trend has continued; according to National Resident Matching Program data, by 2006 only 39% of USMGs matched to first-year positions in internal medicine, pediatrics, or family medicine, leaving still more positions available for IMGs to fill.9 As of 2006, IMGs occupied about half of all first-year family practice residency positions.9 The cumulative effect of this trend is evident in the specialty profile of practicing physicians. More than a quarter (27%) of IMGs practice general internal medicine compared with just 17% of USMGs.10
IMG contributions to underserved areas
By contrast to their clearly disproportionate presence in primary care specialties, the degree to which IMGs fill the need for medical care in rural and other underserved areas is not as clear-cut.11,12 For example, according to 2001 figures, roughly the same proportion of IMGs as USMGs (13.4% compared with 13.7%) were located in metropolitan and nonmetropolitan federally designated Health Professions Shortage Areas (HPSAs).13
However, many IMGs who originally entered the United States on J-1 visas have obtained waivers from the requirement to return to their home countries by agreeing to practice for a time in underserved areas of the United States. J-1 visas are required of foreign medical graduates wishing to enter the country through the Department of State’s Exchange Visitor Program. IMGs with J-1 visas are required to return to their homeland for at least two years following participation in the exchange program before they may apply for permanent work visas. Many IMGs have obtained waivers from this requirement, however, by agreeing to practice in underserved communities. In 2005, according to the U.S. Government Accountability Office, over a thousand such waivers were requested.14 Today, the number of IMGs fulfilling service obligations under the J-1 waiver program is greater than the number of USMGs fulfilling service obligations under National Health Service Corps (NHSC) scholarship and loan repayment programs.13 According to HRSA, NHSC participants are covering about 8% of the unmet needs in HPSAs (USMGs are covering an additional 8% as part of state scholarship and loan forgiveness programs), whereas IMGs with J-1 waivers appear to cover some 25% of these needs; unfortunately, over half of the need remains unmet.13,14 Given the rising debt levels they incur before graduating, many more USMGs probably would be willing to provide care in underserved areas through the NHSC programs; however, the federal appropriation for these programs limits the positions available. Therefore, rather than relying on its own medical graduates to meet the needs of the underserved, the United States continues to rely on non-U.S. citizens educated abroad, including physicians from countries far less developed and less able to afford the loss of valuable human resources.
Further augmenting their contribution to underserved areas, IMGs are twice as likely as USMGs to be employed by city or county governments (3.8% compared with 1.7%).10 This discrepancy suggests that IMGs are disproportionately filling positions in public hospitals that may be less attractive to USMGs.
IMG Contributions to Clinical Practice, Biomedical Research, and Medical Education
One way to illustrate the impact that IMGs have had on U.S. health care is to highlight the contributions of several especially noteworthy individuals. Indeed, examples abound of IMGs who have improved health care delivery, provided care to medically underserved populations, made groundbreaking discoveries in biomedical research, introduced new surgical techniques, pioneered innovative teaching methods, and more. The risk of singling out individuals, of course, is to fail to recognize the countless examples of notable achievements by other IMGs. Nevertheless, the profiles that follow provide a glimpse of the debt America owes to the thousands of foreign-educated physicians who have chosen to dedicate their time and talents to advancing this country’s health care system.
Marianito O. Asperilla, MD
University of Santo Tomas, The Philippines
An infectious disease specialist based in Punta Gorda, Florida, Dr. Marianito O. Asperilla has long cared for medically underserved populations in the United States and abroad. Among his many contributions, he is the founder of the Southwest Florida Disability Foundation for families of people with quadriplegia or paraplegia; he opened a clinic in Port Charlotte, Florida, to provide free health services to uninsured HIV patients; and he co-founded ACCESS Care, Inc., a nonprofit organization through which volunteer doctors have treated more than 10,000 patients in impoverished areas of Central and South America. In recognition of these efforts, Dr. Asperilla was a recipient in 2006 of the American Medical Association’s (AMA’s) prestigious Pride in the Profession Award.15
Anne L. Barlow, MD, MPH
London School of Medicine for Women
For more than 20 years, Dr. Anne L. Barlow has been a driving force behind physician volunteerism in America. After a successful career in pharmaceutical research, in which she became the first female vice president of Abbott Labs, Dr. Barlow began directing her energies toward improving health care for the underserved. She helped found the AMA’s Senior Physicians Group and chaired its governing body for two decades. Today, Dr. Barlow is chair of the American Medical Women’s Association hospital service committee, which oversees free or low-cost health clinics for medically indigent women and children in the United States, as well as in Haiti, India, and Vietnam. Dr. Barlow was honored by the AMA in 2006 with its first Jack B. McConnell MD Award for Excellence in Volunteerism, which recognizes outstanding contributions by a senior physician to medically underserved groups.15
Günter Blobel, MD, PhD
University of Tubingen, Germany
Dr. Günter Blobel is a cellular and molecular biologist with a PhD in oncology. His research has furthered the development of more efficient methods for producing hormones—including insulin, growth hormone, and erythropoietin—for medical use. It also has shed light on diseases such as cystic fibrosis.16 In 1999, Blobel was awarded the Nobel Prize in Physiology or Medicine for his discovery that newly synthesized proteins contain “address tags” that work like molecular zip codes in directing them to the right location within a cell. Currently, Blobel is John D. Rockefeller, Jr. Professor of Cell Biology at the Rockefeller University and an investigator with the Howard Hughes Medical Institute.
Norman E. Rosenthal, MD
University of Witwatersand, South Africa
What once was dismissed as “winter blues” is recognized today as a form of depression, thanks in large part to research by Dr. Norman E. Rosenthal. A psychiatrist and a former researcher at the National Institute of Mental Health, Dr. Rosenthal was the first to describe seasonal affective disorder, and he led the way in developing the field of light therapy to treat the condition. He has written extensively on disorders of mood, sleep, and biological rhythms. He is the recipient of the Anna Monika Award, an international prize for research in depression. Dr. Rosenthal is currently medical director and principal investigator at Capital Clinical Research Associates and clinical professor of psychiatry at Georgetown University.
Arthur H. Rubenstein, MBBCh
University of Witwatersrand, South Africa
Described as a “giant in internal medicine,”17 Dr. Arthur H. Rubenstein has pursued a distinguished career including clinical practice, research, teaching, and medical administration. An internationally renowned endocrinologist, Dr. Rubenstein was part of a team of scientists who in 1979 showed how a genetic mutation leads to an abnormal form of insulin, which in turn results in diabetes. Dr. Rubenstein has been chair of the Department of Medicine at the University of Chicago-Pritzker School of Medicine and dean of the Mount Sinai School of Medicine. He is currently executive vice president of the University of Pennsylvania for the Health System and dean of the University of Pennsylvania School of Medicine. Dr. Rubenstein has also held several national leadership positions, including president of the Association of American Physicians, the Central Society for Clinical Research, and the Association of Professors of Medicine and chairman of the American Board of Internal Medicine.
Ajit K. Sachdeva, MD
All India College, India
A leader in surgical education, Dr. Ajit K. Sachdeva is adjunct professor of surgery, The Feinberg School of Medicine at Northwestern University, and director of the Division of Education at the American College of Surgeons (ACS). In addition to helping found this new ACS division, Dr. Sachdeva has been at the forefront of ACS initiatives on experiential learning, the evaluation of educational outcomes, educational efforts to enhance surgical patient safety, and examination of core competencies in surgery. Before taking the position at ACS, Dr. Sachdeva was a faculty member and vice chairman for educational affairs for the Department of Surgery as well as associate dean for medical education at the MCP Hahnemann School of Medicine (now Drexel University College of Medicine). Additionally, he was chief of surgical services at the Philadelphia Veterans Affairs Medical Center, where he presided over the expansion of tertiary care services staffed by faculty from the University of Pennsylvania School of Medicine and MCP Hahnemann School of Medicine.
Abraham C. Verghese, MD, DSc, MFA
Madras Medical College, India
Perhaps the only physician–author who can rightly claim writer John Irving as mentor, Dr. Abraham C. Verghese, is widely known as an infectious disease specialist with the soul of a poet. Awarded a John Michener fellowship to study at the prestigious Iowa Writer’s Workshop (where Irving was his teacher), Verghese gained national prominence with his best-selling book, My Own Country: A Doctor’s Story.18 In that book, Dr. Verghese chronicles his four years treating AIDS patients in the small Tennessee town of Johnson City and the impact of that experience on his personal life. A former professor of medicine and chief of infectious diseases at the Texas Tech Health Sciences Center in El Paso, Dr. Verghese now oversees the Center for Medical Humanities and Ethics at the University of Texas Health Science Center at San Antonio.
Gabriel Virella, MD, PhD
University of Lisbon, Portugal
As professor of microbiology and immunology at the Medical University of South Carolina for the past 26 years, Dr. Gabriel Virella is widely known for his development of innovative teaching approaches. He played a central role in developing a series of patient-oriented problem-solving exercises for immunology, microbiology, and pathology, and he has authored textbooks on immunology and infectious disease. Additionally, he has made presentations on innovative teaching approaches at workshops and seminars nationwide, and he has received many teaching awards, including the 2003 Alpha Omega Alpha Robert J. Glaser Distinguished Teacher Award.
Elias A. Zerhouni, MD
University of Algiers School of Medicine, Algeria
As director of the National Institutes of Health (NIH) and as a leading expert in radiology and radiological science, Dr. Elias A. Zerhouni has advanced U.S. biomedical research on many levels. In his four years thus far as director of the NIH, Dr. Zerhouni has presided over a doubling of the NIH budget, launched a strategic roadmap designed to hasten scientific discovery, and focused national attention on key issues such as obesity and health disparities. Before coming to the NIH, Dr. Zerhouni held several leadership positions at the Johns Hopkins University School of Medicine, including executive vice dean, chair of the Department of Radiology and Radiological Science, and director of the MRI division. Dr. Zerhouni’s studies on imaging paved the way for advances in computerized axial tomography. Dr. Zerhouni has been recognized by many prestigious societies, including the American Roentgen Ray Society for CT Research.19 Elsewhere in this issue, Dr. Zerhouni presents his personal views about the contributions of IMGs in the United States.
Beneficial Medical Migration or Damaging Brain Drain?
As is evident from the preceding discussion, the United States has benefited enormously from the in-migration of myriad bright and talented physicians who received their medical degrees from other countries. The same can be said of Great Britain, Canada, Australia, and many other developed nations. (In Australia, the United Kingdom, and Canada, as in the United States, fully a quarter of practicing physicians were educated in medical schools elsewhere.20) One country’s gain from in-migration is, quite obviously, another country’s loss from equivalent out-migration. Indeed, considerable concern has been raised recently about the damaging effects of the global migration of physicians on many countries in the developing world—the so-called brain drain. According to a study by Mullan, almost two thirds of the non-U.S. citizen IMGs in the United States come from countries with relatively low income levels.20 For some such countries (e.g., Ghana, Sri Lanka, Haiti), more than 25% of their physician graduates reside elsewhere.20 The impact on the countries of origin of migrating doctors is particularly devastating in areas such as Sub-Saharan Africa, where the physician workforce is already overburdened with HIV/AIDS and other public health catastrophes.
In view of these realities, it is incumbent on the United States (and other “importing” countries) to consider what might be done to offset the negative consequences of America’s (and other country’s) participation in the global physician brain drain.
Working toward self-sufficiency
In theory, the United States could cease importing physicians altogether if its capacity to educate new doctors were sufficient to meet its population’s demand for medical services. Even if we were to aspire to reach this goal, it would be impossible to achieve complete self-sufficiency for several decades, at minimum. Moreover, as a matter of public policy, seeking complete self-sufficiency would violate one of the most cherished principles of America. We are, after all, a country of immigrants. America has always been a haven for those who seek a better life for themselves and their families and for those who seek relief from oppressive circumstances at home. So, a ban on the in-migration of physicians would be unthinkable. This is not to say that substantially reducing that in-migration would not be a socially responsible policy, given the damaging consequences of global physician migration. Indeed, for a rich country such as the United States to depend so heavily on foreign nationals to meet its health care needs is difficult to justify on ethical grounds.
J-1 visas and waivers
As noted previously, many IMGs training in the United States enter the country under the auspices of the Department of State’s Exchange Visitor Program, which requires a J-1 visa. As intended by Congress, the program (which the ECFMG administers for non-U.S. foreign-educated physicians) was designed to facilitate quality medical training for foreign medical graduates, with the expectation that they would return home to improve access to quality medical care for their countrymen. Hence, the J-1 visa holder is obligated, after completion of training, to return home for at least two years before being eligible to apply for immigration to the United States. Over time, many IMGs with J-1 visas have availed themselves of the opportunity to have their return-home requirement waived in return for an agreement to serve for a minimum of two years in an underserved area of the United States.
According to the U.S. Government Accountability Office, the J-1 waiver option has become “a major means of placing physicians in underserved areas of the United States, with more than 1,000 waivers requested in each of the past three years for physicians to practice in nearly every state.”14 Although the J-1 program clearly helps to address certain health care shortages in the United States, the granting of so many waivers contributes to the physician brain drain. Thus, a tightening or restriction of the J-1 waiver process would reduce the U.S. contribution to the global migration problem but would hamper our ability to address the health care needs of underserved U.S. populations, absent some other means for addressing that need.
Strengthening medical education in other countries
Another approach to ameliorating the physician brain drain would be to improve the medical education available to aspiring physicians in “donor” countries. As Mullan observes, “Increased investments by recipient nations in domestic medical education would probably decrease the amount of medical migration from poor countries and increase the medical opportunities for citizens of recipient countries.” Further, he notes, “It would also help lower-income nations to retain physicians and focus training on national needs rather than on the international physician market.”20
How might the United States facilitate such training? One possibility would be to build on the outstanding model of educational exchange provided by the Foundation for Advancement of International Medical Education and Research (FAIMER), a nonprofit foundation of the ECFMG. This program of the FAIMER Institute is designed to foster the professional development of international medical faculty. Knowledge and experience gained by FAIMER fellows working directly with U.S. medical educators on issues relevant to local needs has been a powerful means for advancing the quality of international medical education.
The diversity of topics successfully addressed by this program was highlighted in two issues of the journal Medical Education, which included articles describing the work of FAIMER fellows on:
* Integrating curricular material to improve teaching within a biomedical department (Argentina)21;
* Using portfolios as part of the assessment package during clinical clerkships of a MBChB program (South Africa)22;
* ▪ Integrating a teaching program with student-centered, case-based learning (India)23;
* ▪ Introducing clinical skills training to preclerkship medical students at a resource-constrained medical school (Uganda)24;
* ▪ Advocating program evaluation in new problem-based learning schools (South Africa)25; and
* ▪ Using peer feedback to improve competency at primary care settings (India).26
For 50 years, the ECFMG has helped to assure Americans that their doctors had been well prepared to enter graduate medical education regardless of where they received their undergraduate medical education. As a direct consequence of the ECFMG’s rigorous standards, the United States has been the beneficiary of the contributions of countless IMGs to health care, medical education, research, and public service.
Given the need for a substantial expansion of the physician workforce in the United States to meet the growing need for health care services over the coming decades, it is imperative for the ECFMG to continue to provide this invaluable service. Earlier this year, the Association of American Medical Colleges (AAMC) called for a 30% expansion of U.S. medical schools capacity by 2015. No matter how rapidly U.S. medical schools increase their capacity to meet the predicted doctor shortage, however, U.S. dependence on foreign-educated physicians will doubtless continue and could well increase. Hence, the critical role of the ECFMG in maintaining access to high-quality health care by the American public is certain to be needed for the indefinite future.
Indeed, the ECFMG and its partner FAIMER have the opportunity to amplify their contributions significantly by building on their established programs of international assistance in improving medical education. The AAMC and U.S. medical schools should seek ways to support these efforts. In the increasingly global health care scene, the United States, as the world leader in medical education, has a moral obligation to do what it can to improve the preparation of physicians everywhere and, as a consequence, to improve the health of people worldwide.
The author gratefully acknowledges the assistance of Louise Arnheim of the AAMC Office of Communications in preparing the manuscript. Edward Salsberg and Atul Grover of the AAMC Center for Workforce Studies, Division of Medical School Affairs, and M. Brownell Anderson of the AAMC Division of Medical Education provided much of the data cited in the paper. Hershel Alexander and Jonathan Lang of the AAMC Division of Medical School Services and Studies provided research assistance.