International medical graduates (IMGs) are physicians who have graduated from medical schools outside the United States and seek residency training and permanent practice opportunities in the United States, Puerto Rico, or Canada.1 In the United States, IMGs are integral to the health care system, given the increased recognition of the need for diversity in the workforce2 and an ongoing and worsening workforce shortage.1,3–5 IMGs practice across the 50 states of the United States, including 14 states where they are concentrated in much higher percentages than the national average of 17.6%. As of 2009, the highest concentrations of IMGs were in New Jersey (39.9%), New York (39.7%), Florida (35.2%), and Illinois (32.5%).1 According to the latest data from the National Center for Health Statistics, IMGs are more likely than U.S. medical graduates (USMGs) to practice in primary care shortage areas outside of metropolitan statistical areas (67.8% versus 39.8%), account for one-quarter (24.6%) of all visits to office-based physicians in the United States, are more likely than USMGs (24.9% versus 12.4%) to see minority patients, including Latinos, Asians, and Pacific Islanders, and more likely to see patients expecting to use Medicaid as their primary payment source (17.6% versus 10.2%).6
Important Workforce, Important Needs
IMGs fill critical gaps in the U.S. health care system. However, this important workforce may face important challenges in transitioning to that system. It is widely documented that cultural differences between physicians and patients can shape outcomes related to the patient-provider relationship, trust, and satisfaction with care. Most of the debate surrounding IMGs' transition focuses on overcoming cultural and linguistic barriers.7–11 Little attention has been paid to the influence of IMGs' educational and practice socialization on their medical encounters and other aspects of their clinical practice in the United States.12,13
Since 1998, IMGs have been required to pass exams identical to those administered to USMGs and successfully complete a credentials verification process of the Educational Commission for Foreign Medical Graduates (ECFMG). Nevertheless, IMGs bring considerable heterogeneity in education, training, and clinical experience to the U.S. health care system.14 The existing credentialing requirements do not assess IMGs for their ability to meet the unique challenges of that system, challenges that IMGs may not have been exposed to or even aware of during their medical training or practice in their home countries.
A case in point: Pain is approached and managed in vastly disparate ways in major source countries of IMGs. Using pain treatment as an exemplar, in this article, we contrast the capacity and emphasis placed on pain treatment in the United States with those in some major source countries of IMGs. We believe the situation we describe with pain treatment illustrates the special clinical challenges in many other areas of medicine faced by IMGs in their transition to practice in the United States. We conclude with recommendations to close this transitional gap and explain the need for targeted assessment and training in the clinical domains where there is critical need.
Pain Treatment There and Here: The Transitional Gaps
Pain is a significant public and health policy problem in the United States, affecting one in four individuals15; it is the most common reason that individuals seek medical treatment, representing millions of medical visits annually and costing more than $100 billion each year in health care, loss of productive time, compensation, and litigation.16–18
The widely recognized poor quality of pain treatment in the United States, and the considerable human and financial costs associated with pain and its treatment, have resulted in high-profile policy initiatives. The turn of the millennium marked two important initiatives: the pain standards proposed by the Joint Commission on Accreditation of Healthcare Organization19 and the 106th U.S. Congress's authorization of Title VI, section 1603, of H.R. 3244, declaring the 10-year period beginning in 2001 a “Decade of Pain Control and Research.”20,21 Despite these important initiatives, relevant areas of research, practice, and policy remain untapped. One such area pertains to IMGs and the educational and practice norms they may bring to pain practice in the United States.
In 2010, IMGs in the United States represented 127 countries,5 although the majority were from developing countries, where the standards of pain management are severely low or lacking. Compared with USMGs, IMGs in the United States are equally if not more likely to encounter and treat patients with pain because of the settings and populations they work with. Also, they are more likely than USMGs to work in primary care settings and with poor and medically underserved populations,6 whose members are more likely to experience persistent pain.15 Even though IMGs frequently encounter and treat patients with pain, it is our observation that pain conditions in the United States are often more complex because of much longer life expectancy and more interacting morbidities than in most source countries of IMGs.
Managing these complex patients requires training or experience with analgesic pharmacotherapy and familiarity with pain management approaches. However, the majority of IMGs lack any classroom or experiential exposure to pain management principles or pharmacotherapy during their medical education or clinical practice in their source countries. Although similar observations can be made about lack of pain management education for USMGs, the magnitude of these two scenarios, as illustrated below, are completely different.
Culture of Pain Medicine in Many IMG Source Countries
Macro- and microlevel barriers to the availability of analgesic medicines and their use in some source countries may contribute to IMGs' discomfort with acute and chronic pain management. For instance, India is by far the largest source country for IMGs practicing in the United States, supplying over 20% of all that country's IMG workforce.5 A recent report by Human Rights Watch,22 based on 111 interviews conducted with different stakeholders including patients, physicians, and regulators in India, found major problems with the state of pain management across the states investigated. The following patient account from the report elucidates the typical state of pain treatment in India.
I was in an accident at a construction site.... A wall collapsed on me. People dragged me to the medical college hospital. For two days I had agonizing pain both in the back and the front. I felt like I was going [to become] very weak. I asked to see my children because I thought I would die. I was told that I would be OK.... The doctors said that the pain would go away [by itself]. There was no need to medicate it. I was on an IV and was given lots of medicines. But I was told that no medications were needed for the pain. I was screaming all through the night.22[p18]
The report found that the official curricula for undergraduate and postgraduate medical studies in India do not provide any specific education on pain management. Only about 5 of the more than 300 medical colleges in the country have any formal pain and palliative programs as part of the curriculum. Although a few teaching hospitals offer informal training through rotation of postgraduate students in oncology or anesthesiology, most of the hospitals in the country simply lack such units. One physician told Human Rights Watch that “in medical college, I got zero exposure to pain management. In pharmacology, we got the basics on painkillers but that was it.”22[p111] The report concluded that the vast majority of medical doctors in India are unfamiliar with even the most basic tenets of pain management.
Pakistan, which is among the top five source countries of IMGs practicing in the United States,5 presents a similar scenario of training in pain medicine. Although published data from Pakistan are limited, findings from one survey published in 2004 of Pakistani physicians practicing general medicine and surgery at various teaching hospitals demonstrate physicians' serious lack of knowledge of cancer pain management. When asked about the oral analgesia of choice in terminal cancer pain, 50% were not able to provide an answer, and one-fifth indicated nonsteroidal antiinflammatory drugs to be the oral agents of choice. Less than 13% of physicians indicated oral opioids of any kind as the agent of choice for terminal cancer pain.23 We believe that this example is typical of other types of pain treatment in Pakistan as well.
In addition to lack of education and cultural barriers, principles of pain practice in many source countries are based on the availability of analgesics. This is especially true of opioid pharmacotherapy. The International Narcotics Control Board (INCB) is a quasi-judicial organ under the United Nations, charged with ensuring the availability of opioids for medical use in the countries that were signatories to the 1961 Single Convention on Narcotic Drugs.24 The INCB uses a country's morphine consumption data to assess the adequacy of opioid availability for medical purposes in the country.25 In 2007, the population-adjusted amount of morphine available in the United States was 76.73 mg per capita, whereas only 0.61 mg per capita was available for patients in India, 0.17 mg per capita in the Philippines, 0.34 mg per capita in Mexico, and 0.03 mg per capita in Pakistan.26 These four countries as a group supply about 40% of the IMG workforce in the United States.5
The lack of availability is more dramatic for more expensive preparations such as fentanyl, which simply are not available in many countries. To put this availability in perspective, the amount of fentanyl for medical use available to one person in the United States equals the amount available to 2,323 persons in the Philippines.26 Reasons for the lack of availability of opioids for medical use include stringent narcotic legislation, inability to afford analgesics and opioids, and lack of professional demand. These macrolevel factors in the source countries may relate directly and indirectly to IMGs' experiences with analgesic pharmacotherapy, resulting in a scenario where many IMGs may not have, or rarely have, prescribed an opioid analgesia or ordered a patient-controlled analgesia for acute pain management or sustained-release preparation. In the United States, challenges of lack of foundational education and training in pain management, growing prescription drug abuse, fear of drug enforcement agencies, and litigation culture may further impede comfort with pain treatment for IMGs.
Closing the Gap
IMGs represent an integral and indispensable part of the U.S. health care workforce. IMGs bring a wide range of knowledge and practices from other countries, cultures, and health care systems to the United States. This has potential implications for the quality of care provided by the U.S. physician workforce.14 Thus, to help IMGs provide better care, they may need structured mentoring and socialization into the U.S. medical system. We are not aware of any targeted training that IMGs receive beyond establishing curricular equivalency and credentialing to prepare them for these unique transitional challenges. The ECFMG has recently developed IMG acculturation programs based on “deficit perspective”25; however, these programs are not geared toward “practice acculturation,” that is, the ability to transfer clinical knowledge and skills from the source country and adapt to the practice norms of the country of current practice.
Some developed countries, such as Canada, have implemented models for improving IMGs' integration into the health care system and also have established programs for capacity-building and faculty development to address IMGs' unique needs.27 The United States could leverage and learn from these existing programs.
Capacity-building through faculty development is perhaps the first step toward conceptualizing and implementing effective transitional programs for IMGs in the United States. The Association of Faculties of Medicine of Canada has implemented one such program with the goal of preparing teachers in diverse settings to work effectively and collaboratively with IMGs and to enhance their learning and practice experience. The program consists of various sections and modules, including orientation for teachers and IMGs and teaching faculty development principles and strategies that focus on educational methodologies to be used in the program. The program also provides a faculty “toolbox” for working with IMGs, including assessing learners' needs, delivering effective feedback, fostering skills and strategies needed to promote patient-centered care communication among IMGs, and providing focused training and supervised mentorship on selected clinical skills—such as physical examination, evidence-based medicine, literature searching, and medical literacy skills—that are frequently noted as posing difficulties for IMGs when adapting to the Canadian medical culture.27 The content and process of education in the program are not fundamentally different from current methods of faculty development. However, certain topics and concepts are strategically emphasized in order to effectively address the problems encountered by IMGs. Such a priority-based, tailored model could be incorporated into the current residency programs in the United States.
Similar to the Canadian model described above, where training is focused on high-priority areas, one strategy for the United States may be to map the current status of education and clinical training in the top 10 countries that are the sources of IMGs practicing in the United States. The mapping project could be a collaborative effort of the Accreditation Council for Graduate Medical Education and the Foundation for the Advancement of International Medical Education and Research, which promotes excellence in international health professions education through programmatic and research activities. Content areas for the mapping project should be selected strategically from a menu of high-impact areas of clinical and public health needs in the United States (e.g., pain treatment that cuts across clinical fields). The findings may offer a vantage point for conceptualizing and developing the targeted training opportunities in the United States. IMGs should be involved as the stakeholders in every phase of program design and implementation.
IMGs may benefit from faculty who are skilled in training IMGs as well as from structured orientation and transitional programs that focus on medical socialization, language resources, and cultural diversity training.28 From a medical or practice socialization standpoint, IMGs need training not only in the macroculture of the U.S. health care system but also in the microculture and peculiarities of the specific practice contexts in which IMGs are to function.29
Our discussion of IMGs and pain management is only an exemplar to illustrate the special clinical challenges faced by IMGs in many areas of medicine as they learn to practice in the United States. We believe that early and smooth practice acculturation could lead to enhanced morale among IMGs and improved patient care and outcomes. Continuous acculturation approaches should be incorporated at various entry points—before arrival, before orientation programs, and during ongoing curriculum that focuses on IMGs.
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17 The Mayday Fund Special Committee on Pain and the Practice of Medicine. A Call to Revolutionize Chronic Pain Care in America: An Opportunity in Health Care Reform. http://www.maydaypainreport.org/report.php
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