The U.S. primary care workforce is facing numerous challenges. The federal government’s recent health care reform efforts are likely to lead to greater demand for physician services, particularly primary care.1 The Association of American Medical Colleges2 estimates, however, that the nation is on track to have about 45,000 fewer primary care physicians than it will need by 2020. Many Americans live in areas where the availability of primary care services is already limited, and the needs of newly insured patients will exacerbate existing access problems.3 At the same time, trends in U.S. demographics—including population growth, aging, and an increase in lifestyle diseases—are expected to intensify the need for primary care physicians.3
Compounding the crisis, fewer graduates of U.S. MD-granting medical schools (USMGs) are choosing primary care specialties. Among a sample of 1997–2006 USMGs, specialty choices decreased over time in the fields of general medicine, family medicine, general pediatrics, and obstetrics–gynecology.4 If these trends continue, recent increases in the number of U.S. MD-granting medical schools and in class sizes are unlikely to result in appreciably higher numbers of primary care physicians; rather, they may contribute to worsening health care costs and access problems.5
Numerous solutions to these challenges have been proposed,3,6–9 such as providing training in outpatient settings and loan forgiveness programs. However, because of philosophical disagreements, the complexity of legislative change, and cost issues, no clear and simple strategy has emerged that will ensure a sufficient workforce of primary care physicians now and in the future.
Although the majority of physicians in residency training and practice in the United States are USMGs, approximately 25% are graduates of international medical schools (IMGs).10 Studies have shown IMGs to be more likely than USMGs to specialize in primary care disciplines11 and to practice in rural areas.12 In 2005–2006, 24.6% of all visits to office-based physicians were to IMGs.11
The source countries of IMGs have been changing over time. The number of graduates of Caribbean medical schools (C-IMGs) certified by the Educational Commission for Foreign Medical Graduates (ECFMG)* has increased each year since 2000.13 In 2006, only 1,860 (17.2%) of the 10,818 ECFMG-certified IMGs graduated from Caribbean medical schools; by 2011, 2,936 (30.0%) of the 9,791 physicians certified graduated from institutions located in the Caribbean.14 The number of medical schools in the Caribbean region† has also grown since 2000: Of the 63 open Caribbean medical schools listed in the International Medical Education Directory in 2012, just 38 were established before 2000, whereas 12 were established during 2000–2005 and 13 have opened since 2006.15 Many of these schools recruit, almost exclusively, U.S. citizens and international students who intend to pursue residency training and licensure in the United States.16
Concerns have been raised regarding the quality of the education provided at Caribbean institutions in light of the rising number of C-IMGs seeking residency and practice opportunities in the United States, the number of recently established schools in the region, and the lack of a uniform system of quality assurance oversight for the region’s medical schools.16–18 Recent studies13,19–22 have documented that, on average, C-IMGs seeking to enter graduate medical education (GME) programs in the United States do not perform as well on qualifying exams and other proxy measures of ability as do USMGs or graduates of international medical schools in non-Caribbean countries (non-C-IMGs). Nevertheless, many C-IMGs eventually pass the requisite examinations, achieve ECFMG certification, obtain GME positions, and go on to unsupervised practice in the United States.19
Although medical education in the Caribbean region is often viewed as uniform, there is evidence of wide variation in medical schools’ selection processes, clinical training opportunities, and student performance.16 Whereas some schools may be small or underresourced, several are accredited by agencies that have been deemed to use criteria comparable to the standards used to accredit U.S. medical schools.23 In addition, there is evidence that the average performance of C-IMGs on the United States Medical Licensing Examination (USMLE) has been improving.13
These physicians, whose role in patient care in the United States is often overlooked, represent a potentially valuable human resource for the delivery of primary care services. The majority of the C-IMGs certified by the ECFMG are from North America and desire practice opportunities in the United States: Of the 2,936 ECFMG certificates issued in 2011 to C-IMGs, 2,024 (69.0%) were awarded to U.S. citizens and 422 (14.0%) to Canadian citizens.14 Given that various parties have attempted to limit C-IMGs’ training opportunities and practice settings,24,25 we believe it is important to consider this group of physicians’ current and prospective workforce contributions, particularly in primary care specialties where there is great need. We therefore conducted this study to quantify C-IMGs’ contribution to the U.S. primary care workforce.
We obtained May 2011 American Medical Association (AMA) Physician Masterfile data from the AMA. The Physician Masterfile26 includes current and historical data for more than one million physicians and residents in the United States, and its physician records are continuously updated through extensive data collection activities. We also obtained demographic data for IMGs (e.g., country of medical school from which they graduated, citizenship) from ECFMG’s database of IMGs who have applied for ECFMG certification. Using common identifiers (USMLE identification numbers), we merged the ECFMG and Physician Masterfile data.
We used the combined data to analyze the cohort of physicians who, as of May 2011, had completed their GME training and were directly involved in patient care (defined as office-based practice or employment as full-time hospital staff). Although residents are typically directly involved in patient care activities, the proportion of residents in primary care disciplines (e.g., internal medicine, pediatrics) who will eventually subspecialize is difficult to estimate. Therefore, we did not include residents in our study population.
We classified all physicians in the study population into four mutually exclusive categories according to the type of medical school from which they graduated:
* USMGs, and
* DOs (graduates of U.S. DO-granting medical schools).
Definition of primary care
For the purposes of this study, we defined a physician as practicing primary care if he or she self-declared his or her specialty or subspecialty as one of the following: internal medicine; geriatric medicine (internal medicine); adolescent medicine (internal medicine); internal medicine/family medicine; internal medicine/pediatrics; family medicine; geriatric medicine (family medicine); general practice; pediatrics; adolescent medicine (pediatrics); nutrition; or public health and general preventive medicine. (It should be noted that the term “general practice,” although no longer used to describe a specialty, is historical and remains in the Physician Masterfile data.) We defined all other self-declared specialties and subspecialties as not primary care.
Our definition of primary care is more restrictive than the AMA’s,26 which includes numerous internal medicine subspecialties (e.g., sports medicine, nephrology) and pediatric subspecialties (e.g., pediatric allergy, pediatric gastroenterology). The only subspecialties of internal medicine and pediatrics that we considered to be primary care are listed above. In addition, it should be noted that our definition of primary care does not connote certification by any member board of the American Board of Medical Specialties or American Osteopathic Association. Many IMGs practicing in primary care fields are not board certified. Finally, on the basis of other descriptions of primary care in the literature,3,6 we did not include obstetrics–gynecology as a primary care specialty in this study.
We analyzed the data in January 2012. First, we categorized the physicians involved in direct patient care according to their practice setting (office-based practice versus full-time hospital staff), our four physician classifications (C-IMGs, non C-IMGs, USMGs, DOs), and physicians’ self-designated specialties (primary care versus not primary care). Because many physicians who were full-time hospital staff were likely to be hospitalists rather than primary care providers, we also conducted separate analyses using data for only the physicians in office-based practice. Finally, we calculated the frequencies and percentages of self-designated primary care specialties for each of our four physician classifications.
We did not submit this study for review by an institutional review board, for several reasons. First, this study involved no known risks to participants. Second, ECFMG certification applicants acknowledge that their data can be used for research purposes, and they are provided with an option to not allow their examination data to be included in research. Third, the selection of participants was equitable because ECFMG applicants voluntarily chose to seek ECFMG certification. Fourth, all applicable data in the AMA Physician Masterfile were included in the analysis; we did not use a sample of the data. Fifth, personal identification information was not used in the data analysis; records were linked using common identifiers. Finally, only group-level results were obtained and reported.
There were 698,431 physicians listed in the AMA Physician Masterfile in a direct patient care practice category (office-based practice or full-time hospital staff) as of May 2011. Our study population consisted of the 684,469 (98%) physicians for whom data were also available concerning the medical school from which they graduated (allowing us to determine physician classification) and self-designated specialty. About one-quarter of these physicians were IMGs (C-IMGs: 3.0%, n = 20,333; non-C-IMGs: 20.4%, n = 139,415), and about three-quarters were graduates of U.S. medical schools (USMGs: 70.3%, n = 481,061; DOs: 6.4%, n = 43,660). Physicians’ mean years since medical school graduation were as follows: 21.2 for C-IMGs, 29.3 for non-C-IMGs, 24.6 for USMGs, and 20.3 for DOs. Table 1 presents data on the numbers and proportions of physicians in direct patient care, stratified by physician classification and specialty (primary care versus not primary care).
Overall, C-IMGs had the highest proportion of physicians practicing in primary care disciplines (56.7%; n = 11,530 of 20,333), whereas USMGs had the lowest (32.9%; n = 158,077 of 481,061). The proportions were similar in our analysis of only the physicians in office-based practice: C-IMGs (57.7%; n = 10,370 of 17,972) were the most likely to be practicing in a primary care specialty, whereas USMGs were the least likely (33.4%; n = 141,630 of 424,392).
The most frequently self-reported primary care specialties were internal medicine, family medicine, pediatrics, and general practice (Table 2). There were few appreciable differences in proportions across the four physician classifications, with one exception. DOs were more likely than other physicians to report that they practiced family medicine; they were also more likely to report practicing family medicine than any other primary care specialty.
Ensuring a sufficient supply of primary care physicians in the United States over the coming decades will be challenging. Fewer USMGs are choosing primary care specialties than have in the past, a trend that is expected to continue given current economic realities.27 Meanwhile, health care reform and shifting demographics are expected to increase the demand for primary care and preventive services,1 exacerbating the access problems that already exist in some parts of the county.3
Although some primary care services can be provided by other health professionals (e.g., physician assistants, nurse practitioners), the need for primary care physicians is well documented.1 IMGs have historically contributed to the U.S. primary care workforce,11,12 and, given the steady numbers of applicants for ECFMG certification over the past several years,14 they are likely to continue to do so. Research into IMGs’ demographics and practice characteristics—particularly the roles that different IMG groups play in primary care—could help inform U.S. physician workforce policies.
We therefore conducted this study to quantify the contribution of C-IMGs to the primary care workforce in the United States. Our findings indicate that C-IMGs are more likely to practice in a primary care specialty (56.7%) than are non-C-IMGs (42.3%), USMGs (32.9%), or DOs (54.0%). We believe that our cross-sectional results can be used to project C-IMGs’ future contributions: Because most C-IMGs are U.S. citizens who, it can be argued, are likely to remain in the United States after residency training, we suggest that the proportion of C-IMGs contributing to the primary care workforce is likely to remain higher than that of the other groups of physicians. It should be noted that the GME opportunities for IMGs, especially in highly competitive non-primary-care disciplines, are likely to remain restricted.10
Although it is unknown to what degree C-IMGs choose to practice primary care and to what degree they enter primary care on the basis of the perceived probability of acceptance into a residency program, it is clear that C-IMGs help meet an important need in the U.S. health care system. Although C-IMGs may perform less well, on average, than USMGs on examinations required for ECFMG certification, most of the C-IMGs who achieve ECFMG certification are able to secure a residency position.19 If past trends persist, as we note above, high proportions of C-IMGs will continue to contribute to the primary care workforce.
The most common self-designated primary care specialties among our study population of physicians involved in direct patient care were internal medicine, family medicine, pediatrics, and general practice. Approximately three-quarters of physicians in each of our four classifications practiced either internal medicine or family medicine. The proportions of C-IMGs were similar to those of the other groups of physicians for each specialty. Interestingly, C-IMGs and DOs were more likely than non-C-IMGs and USMGs to indicate that they were general practitioners. “General practice” is no longer a specialty option for new physicians in the AMA Physician Masterfile, and its use reflects historical data. The characteristics (e.g., board certification) and practice patterns of this group should be investigated in future studies.
This study has limitations. First, the AMA Physician Masterfile relies on some self-reported data and may have inaccuracies or omissions. Data may also lag behind actual practice. Second, our inclusion of certain specialties (i.e., public health and general preventive medicine; nutrition) as primary care disciplines may not be in line with other definitions of primary care. However, the number of physicians who indicated these specialties was too small to affect the results significantly. Third, our use of self-designated practice specialty in conjunction with our definition of primary care may not perfectly delimit all physicians in primary care roles. Although board certification in a primary care field, without secondary specialization, may be a better indicator of actual primary care practice, we could not use that criterion in this study because many IMGs are not board certified. Nevertheless, to the extent that classification errors are consistent across our defined cohorts (C-IMGs, non-C-IMGs, USMGs, DOs), our findings should be generalizable. Fourth, our study population of physicians providing direct patient care included full-time hospital staff; this group likely included internal medicine generalists who were not primary care providers. Nonetheless, when we examined data for only physicians in office-based practice, we found that the proportions of physicians practicing primary care in each of our four physician classifications were similar to those of all physicians in the study (i.e., C-IMGs were most likely to practice primary care, followed by DOs, non-C-IMGs, and, finally, USMGs).
Fifth, although residents provide direct patient care, we did not include them in our study population. C-IMGs may perceive GME positions in primary care as less competitive than those in other specialties and may therefore be disproportionately attracted to primary care fields at entry. After completing their residency training in a primary care discipline, C-IMGs may go on to specialize. Omitting the resident cohort may therefore contribute to an underestimate of the proportion of C-IMGs currently in primary care. Sixth, although the proportion of physicians practicing primary care was highest among C-IMGs, the absolute numbers should be considered when evaluating C-IMGs’ contribution to the U.S. health care workforce. It should be noted, though, that annual ECFMG certification and registration data indicate that the number of C-IMGs seeking training opportunities in the United States is increasing.14
Sixth, this cross-sectional analysis did not explore any potential differences in specialty choice or practice location on the basis of when physicians entered the workforce. Future work should investigate trends in C-IMGs’ specialty choices and their practice locations over time. Finally, we did not investigate the quality (and efficiency) of care provided by these practitioners. Additional studies aimed at quantifying patient care outcomes by provider group are certainly needed.28
In conclusion, more than half of C-IMGs involved in direct patient care in the United States are practicing in primary care specialties. Although their absolute numbers are low, they are making an important contribution to the primary care workforce and helping to meet the country’s need for primary care services. Many forces may change the physician landscape in the future, including increased enrollment at U.S. medical schools, the overall availability of GME positions, and programs to encourage U.S. medical students to practice in primary care fields. However, in light of past trends, it seems likely that U.S. medical students will continue to favor careers in non-primary-care specialties. Given the current and projected need for primary care services, we must look to other qualified practitioners to fill the gap. At least in the short term, C-IMGs—many of whom are U.S. citizens and familiar with the nation’s health care system—are an important resource.
Other disclosures: None.
Ethical approval: The authors did not submit this study for review by an institutional review board, for several reasons. First, this study involved no known risks to participants. Second, ECFMG certification applicants acknowledge that their data can be used for research purposes and can opt to not allow their examination data to be included in research. Third, the selection of participants was equitable because ECFMG applicants voluntarily chose to seek ECFMG certification. Fourth, all applicable data in the AMA Physician Masterfile were included in the analysis. Fifth, personal identification information was not used in the data analysis. Finally, only group-level results were obtained and reported.
* All IMGs must complete the ECFMG certification process before they can enter U.S. residency programs approved by the Accreditation Council for Graduate Medical Education. ECFMG certification is also a prerequisite to IMGs’ subsequent licensure and unsupervised practice. Cited Here...
† Countries in the Caribbean region with medical schools include Anguilla, Antigua and Barbuda, Aruba, Barbados, Bonaire (special municipality of the Netherlands), Cayman Islands, Cuba, Curacao, Dominica, Dominican Republic, Grenada, Haiti, Jamaica, Montserrat, Saba (special municipality of the Netherlands), Saint Kitts and Nevis, Saint Lucia, Saint Vincent and the Grenadines, Sint Eustatius (special municipality of the Netherlands), Sint Maarten, and Trinidad and Tobago. (Medical schools in Puerto Rico are accredited by the Liaison Committee on Medical Education.) Cited Here...
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