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Comparing International and United States Undergraduate Medical Education and Surgical Outcomes Using a Refined Balance Matching Methodology

Zaheer, Salman MD*,†; Pimentel, Samuel D. BS; Simmons, Kristina D. PhD; Kuo, Lindsay E. MD, MBA*,†; Datta, Jashodeep MD*; Williams, Noel MD*; Fraker, Douglas L. MD*; Kelz, Rachel R. MD, MSCE*,†

doi: 10.1097/SLA.0000000000001878

Objective: The aim of this study is to compare surgical outcomes of international medical graduates (IMGs) and United States medical graduates (USMGs).

Summary of Background Data: IMGs represent 15% of practicing surgeons in the United States (US), and their training pathways often differ substantially from USMGs. To date, differences in the clinical outcomes between the 2 cohorts have not been examined.

Methods: Using a unique dataset linking AMA Physician Masterfile data with hospital discharge claims from Florida and New York (2008–2011), patients who underwent 1 of 32 general surgical operations were stratified by IMG and USMG surgeon status. Mortality, complications, and prolonged length of stay were compared between IMG and USMG surgeon status using optimal sparse network matching with balance.

Results: We identified 972,718 operations performed by 4581 surgeons (72% USMG, 28% IMG). IMG and USMG surgeons differed significantly in demographic (age, gender) and baseline training (years of training, university affiliation of training hospital) characteristics. USMG surgeons performed complex procedures (13.7% vs 11.1%, P < 0.01) and practiced in urban settings (79.4% vs 75.6%, P < 0.01) more frequently, while IMG surgeons performed a higher volume of studied operations (50.7 ± 5.1 vs 57.8 ± 8.4, P < 0.01). In the matched cohort analysis of 396,810 patients treated by IMG and USMG surgeons, rates of mortality (USMG: 2.2%, IMG: 2.1%; P < 0.001), complications (USMG: 14.5%, IMG: 14.3%; P = 0.032), and prolonged length of stay (pLOS) (USMG: 22.7%, IMG: 22.8%; P = 0.352) were clinically equivalent.

Conclusion: Despite considerable differences in educational background, surgical training characteristics, and practice patterns, IMG and USMG-surgeons deliver equivalent surgical care to the patients whom they treat.

*University of Pennsylvania, Perelman School of Medicine, Department of Surgery, Philadelphia, PA

Hospital of the University of Pennsylvania, Department of Surgery, Center for Surgery and Health Economics, Philadelphia, PA

University of Pennsylvania, Wharton School, Department of Statistics, Philadelphia, PA.

Reprints: Rachel R. Kelz, MD, MSCE, FACS, Hospital of the University of Pennsylvania, 3400 Spruce Street, 4 Silverstein, Philadelphia, PA 19104. E-mail:

RRK is funded by a grant from the National Institute on Aging, #1R01AG049757-01A1. The content of this manuscript is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. SDP is funded under FA9550-11-C-0028 by the Department of Defense, Army Research Office, National Defense Science and Engineering Graduate (NDSEG) Fellowship, 32 CFR 168a. The dataset used for this study was purchased with a grant from the Society of American Gastrointestinal and Endoscopic Surgeons. Although the AMA Masterfile data is the source of the raw physician data, the tables and tabulations were prepared by the authors and do not reflect the work of the AMA. The authors declare no conflicts.

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