Acad Psychiatry 31:68-83, January-February 2007
doi: 10.1176/appi.ap.31.1.68
© 2007 Academic Psychiatry
An Annotated Bibliography of Professional Literature on International Medical Graduates
Nyapati R. Rao, M.D.,
Milton Kramer, M.D.,
Ramotse Saunders, M.D.,
Stuart W. Twemlow, M.D.,
James W. Lomax, M.D.,
Mantosh J. Dewan, M.D.,
Michael F. Myers, M.D.,
Jeff Goldberg, M.D.,
George Cassimir, M.D.,
Brunhild Kring, M.D. and
Othmane Alami, M.D.
Received November 27, 2005; revised May 4, 2006; accepted May 12, 2006. Drs. Rao, Kramer, Saunders, Twemlow, Lomax, Dewan, Myers, Goldberg, Cassimir, and Kring are affiliated with the Group for Advancement of Psychiatry, Dallas, Texas. Dr. Alami is affiliated with the Department of Psychiatry, SUNY Downstate Medical Center, Brooklyn, New York. Address correspondence to Dr. Rao, Department of Psychiatry and Behavioral Sciences, 2201 Hempstead Turnpike, East Meadow, NY 11554; nrraomd{at}pol.net
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INTRODUCTION
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In the professional medical literature, bibliographies are compiled mostly on clinical subjects to enable better patient care through the acquisition of comprehensive knowledge and skills by clinicians (1–8). One may wonder about the need for an annotated bibliography on a group of physicians, international medical graduates (IMGs), who do not belong to the traditional focus of topics among bibliographies. IMGs constitute 25% of physicians in the U.S. workforce (9). In addition, they comprise 18% of clinical science faculty and 21% of basic science faculty in U.S. medical schools (10). In American psychiatry, IMGs comprise 36.4% of all psychiatry residents (11) and 27.5% of all members of APA (12). They are a heterogeneous group of physicians who come from vastly different cultural, linguistic, and medical education backgrounds than do their American counterparts. They play a key role in the delivery of health care, especially to underserved populations, and it is opined that their practice patterns differ from their U.S. counterparts (13, 14).
In spite of the large number of IMGs in American medicine, and the key role they play in service delivery, there exists a considerable lack of awareness and knowledge of the issues that impinge on their education and practice of medicine. Concerns have been expressed about deficiencies in their medical education, the alleged poor quality of care that they provide, and their lack of cultural and linguistic competence (15, 16). It is also stated that there exists a two-tiered training system in which U.S. medical graduates (USMGs) are trained in predominantly academic medical centers whereas IMGs are trained in resource-poor training programs (17).
Based on the aforementioned figures, IMGs represent a significant portion of physicians and psychiatrists working and training in the United States and face unique issues. In the current climate of heightened focus on competence in medical education and practice, it is important that a concerted effort be made to address the issues that confront IMGs in training and practice and to integrate them fully into our profession. To that end, the IMG Committee of the Group for the Advancement of Psychiatry (GAP) decided to compile a bibliography of existing literature on IMGs. This was done to offer to the field the current state of scholarly knowledge regarding IMGs, to highlight lacunae in the existing knowledge, and to foster future research in this area. It is hoped that with enhanced awareness of IMG issues and better appreciation of their needs in residency training, strategies to address these issues will emerge. Similarly, a greater understanding of their quality-of-life issues, caused by immigration and cultural differences, will engender measures to fully integrate them in the field. A highlighting of their positive contributions to the field will, it is hoped, lead to improved morale and confront familiar stereotypes against them. These more evolved perspectives and interventions relevant to IMGs may lead to a shift from the existing two-tiered system to one in which there is greater integration and parity between USMGs and IMGs. For patients this extends beyond the mere availability of a psychiatrist in the so-called "safety net" (14) model to the delivery of improved care.
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Method
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A comprehensive review, utilizing MEDLINE, PubMed, and PsycINFO databases of IMG literature in the English language published between 1966 and 2005, was performed and 107 articles were included in this bibliography. These articles addressed issues specific to IMGs in both U.S. and international literature, and articles involving cross-cultural issues but not focused on the IMG were removed. For example, articles dealing with the doctor-patient relationship between a Western physician and a patient from a non-Western culture were eliminated. The review was further supplemented by a manual search of peer-reviewed journals, scholarly publications and monographs. After reviewing all of the references obtained, the Committee narrowed the recurring themes in IMG literature to the following: workforce, acculturation, education and training, quality and competence, and discrimination. These categories were chosen to encompass the gamut of the IMG experience, and though they overlap to some extent, the consensus of the Committee was that they were thematically distinct enough to warrant their use. The Committee also decided to include important contributions made in IMG literature from nonpsychiatric disciplines, in order to broaden the field of ideas for the reader. In recognition of a similar body of literature from other English-speaking countries with a large pool of IMGs, selections from the international literature were included.
The Committee, consisting of several senior IMG and USMG psychiatrists from diverse backgrounds of clinical practice, education, training, administration, and research, reviewed the issues affecting the IMG experience and compared these with the thematic issues addressed in the existing literature. The purpose of this review and comparison was to assess whether certain aspects of IMG issues had been completely excluded from the literature; the outcome was the recognition of a plethora of articles addressing educational deficits, but none proposing effective supervisory and training strategies to deal with them (e.g., the education of an IMG resident in long-term psychotherapy in a culturally sensitive manner). In spite of the field currently having several highly accomplished IMG researchers, there is a dearth of articles on strategies to engage IMGs in clinical research training. The general tone of many articles is one of embarrassment and frustration with this group of residents, with little recognition of their positive contributions.
In the area of workforce, the focus in the literature has been on the twin issues of physician supply and maldistribution, and the contribution made by IMGs to both. The long held view has been that the U.S. physician surplus has been exacerbated by the uncontrolled migration of IMGs with varying medical educational backgrounds. Even though this literature tends to portray the IMG as a problem, lately there has been a growing recognition of the positive impact that IMG presence has made on redressing physician maldistribution in the American economy. However, compared with the general medical literature on workforce, psychiatric literature tends to be somewhat narrowly focused on how to select the best IMG resident, or the delineation of practice patterns of psychiatrists. Vigorous longitudinal studies of professional development of IMGs are lacking.
In the area of acculturation, studies documenting cultural differences between various groups of IMG residents, the impact of immigration stressors, residents’ receptivity to American-style training, and effective strategies to engage them are absent. Much emphasis, understandably, has been placed on improving IMG residents’ linguistic competence and, in the process, getting them better acculturated. However, the impact of culture on language development is not addressed. Considering the topic of discrimination, it seems that nonpsychiatric specialties are much more forthright in addressing discrimination issues. There are very few studies documenting discriminatory practices against IMGs in psychiatry.
Similarly, in education and training, as mentioned earlier, effective strategies to help residents pass board examinations, or become effective psychotherapists or productive clinical researchers, are sparse. Concerning board certification, more recent data on IMG performance is lacking and much prominence is given to the two-decades-old data on their low pass rates. In the area of quality and competence issues, IMGs have traditionally been seen as physicians with many deficits. Rigorous data are lacking in this field, and the few studies that exist are based on attitudinal surveys. A more comprehensive examination of quality through the use of the advanced evaluation techniques made available by the core competency requirements, data on physician performance from managed care and regulatory bodies, and a more transparent use of board certification performance and Psychiatry Resident-in-Training Examination (PRITE), are needed. Similar issues pertain to psychosocial domains of residency training.
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Conclusions
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The compilation of this annotated bibliography has revealed deficiencies in our knowledge to date on the international medical graduate, both in psychiatry and in the larger field of medicine. We noticed a particular dearth of articles dealing with discrimination and quality/competence within the field of psychiatry itself. This by no means suggests that work in the domains of acculturation, workforce issues, and education is complete. International medical graduates, with their diverse origins and exposures, defy simple categorization. However, the category breakdown of acculturation, workforce, education and training, discrimination, and quality and competence does serve as a useful template for organizing this bibliography. Nevertheless, as research in this field advances, and as IMG issues evolve, it may very well be that a different categorization may become more appropriate. In the following, annotated articles are mentioned chronologically in the categories mentioned above.
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Bibliography of International Medical Graduates’ Psychiatric Literature
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Acculturation
This section includes aricles on acculturation issues that impinge on international medical graduates (IMGs) in psychiatry.
1. Rao NR: The influence of culture on learning of psychiatry: the case of Asian-Indian IMGs. Int J Appl Psychoanal Res, in press
Culture is ubiquitous and fundamental to the practice and learning of psychiatry. Using Asian-Indian IMGs as an example, the educational challenges faced by IMGs in learning psychiatry are reviewed. These difficulties are traced to the significant psychological impact of migration on IMGs, their cultural conflicts in using English as a second language, and the differing attitudes toward mental illness in Eastern and Western cultures. To further delineate the Asian-Indian cultural hurdles in learning psychiatry, the impact of the Hindu world view on their individual psychologies and their interpersonal relationships is discussed. An example from a psychotherapy session of a resident is offered to highlight the issues raised in this article.
2. Sierles FS: Using film as the basis of an American culture course for first-year psychiatry residents. Acad Psychiatry 2005; 29:100–104
This article discusses using film to about and expose IMGs to American culture. Measured resident satisfaction was high, and it was concluded that feature films are a useful tool for teaching American culture to IMGs.
3. Myers GE: Addressing the effects of culture on the boundary-keeping practices of psychiatry residents educated outside of the United States. Acad Psychiatry 2004; 28:47–55
This article proposes a curriculum on enhancing IMGs’ confidence in dealing with boundary issues in psychiatric training and practice by addressing their culture-based deviations from normative boundary-keeping practices common to U.S.-based psychotherapy practices.
4. Lijtmaer RM: Countertransference and ethnicity: the analyst's psychic changes. J Am Acad Psychoanal 2001; 29:73–83
Cultural differences between patient and therapist will influence transference-countertransference reactions. The analyst’s reactions, or cultural countertransference, can be used as a tool to facilitate the optimization of therapeutic distance. Mindfulness of this cultural countertransference is important as it relates to aspects of the analyst’s ethnocultural self that are normally unconscious. A case presentation of a Latino therapist and Chinese patient is used to illustrate these principles. The issues are relevant to IMG training.
5. Akhtar S: Immigration and Identity: Turmoil, Treatment, and Transformation. Northvale, NJ, Jason Aronson, 1999
A detailed and sensitive psychological examination of the impact of immigration on identity and its implications for psychotherapy of immigrants, both for the patient and the therapist. A must-read for those working psychologically with immigrants.
6. Husain SA, Munoz RA, Balon R: Acculturation and adaptation of international medical graduates in the United States, in International Medical Graduates in Psychiatry in the United States: Challenges and Opportunities (Issues in Psychiatry). Arlington, Va, American Psychiatric Press, 1997, pp 21–29
This study examines the attitudes of Asian IMGs towards various cultural scenarios. Results showed that many IMGs working in a university or in a public or state facility report difficulties in cultural adaptation that IMGs working in independent practice do not encounter.
7. Desai P: Learning psychotherapy: a cultural perspective. J Oper Psychiatry 1982; 13:82–87
Understanding culture-specific predispositions can facilitate learning. This article notes that healers operate within their own cultural context and points to areas of difference in assumptions between Hindus and Americans about the past and the present, individual expression or suppression, inner consistency, pessimism or optimism, the unconscious, dependence, sexuality, and transference.
8. Desai P, Coelho G: Indian immigration in America: some cultural aspects of psychological adaptation, in The New Ethics: Asian Indians in the United States. New York, Praeger, 1980
A detailed and comprehensive review of problems faced by Hindus immigrating to the United States which focuses on culture-specific predispositions. The history of the immigration, culture shock, issues of authority and dependency, roles and expectations, loneliness and connections, achievement and affiliation, conflict and its resolution, parents and children, adaptation, overidentification, psychological casualties, and help-seeking behavior are all explored and related to sacred texts and beliefs.
9. Haveliwala YA: Problems of foreign born psychiatrists. Psychiatr Q 1979; 51:307–311
This article reviews problems: language, psychiatric knowledge gap, issues with patients, learning a new culture, discrimination, ignorance of medical culture, and the business of medicine. It also lists some positives of being a foreigner.
10. Arthur GK, Brooks R, Lopez-Long M: A language-cultural course for foreign psychiatry residents. Am J Psychiatry 1979; 136:1064–1067
IMGs typically come from cultures alien to ours, where the first language is not English, and with little training in psychiatry. Intrapersonal, interpersonal, and sociocultural adjustment problems of psychiatry residents are identified. These problems were used in an informal group discussion to delineate the adjustment issues that the foreign resident experiences. Pre- and post-tests showed clear improvement, as did anecdotal reports of the residents’ performance.
11. Forrest DV, Ryan JH, Lazar V: American familiar language and the FMG psychiatry resident. J Psychiatr Educ 1978; 2:68–82
Effective communication of emotion in American psychiatry relies heavily upon American familiar and slang expressions. It is commonly noted that foreign medical graduates (FMGs) have problems in slang usage. This study examined the effects of a 55-hour American familiar language and culture course on FMG competence. Test results indicated that the course greatly improved FMG familiar language capability. It was suggested that improved language competence would facilitate an improved empathic connection with patients.
12. Schmiedeck RA: The foreign medical graduate and the nature of emigration. Psychiatr Opin 1978; 15:38–40
This article identifies emigration and immigration as separate processes for the FMG. Emigration focuses on detachment from the parent culture, and immigration on acceptance of the adopted culture. The response to these processes and their subcomponents is viewed as fluid and interactive. A comparison is made to the individuation processes of adolescence.
13. Lin T: Psychiatric training for foreign medical graduates: a symposium: I: introduction. Psychiatry 1971; 34:233–234
After an analysis of the problems faced by IMG trainees, it was suggested that APA conduct a survey of foreign doctors working in the United States, establish pilot training programs, and initiate bilateral interaction with training programs in developing countries.
14. Char WF: Psychiatric training for foreign medical graduates: a symposium: the foreign resident: an ambivalently valued object. Psychiatry 1971; 34:234–238
Problem areas may arise from residency, family, personality, language, understanding culture, reality, education, or society. The author makes recommendations for FMGs to be treated as individuals, for courses in language and culture, and for help with reality problems, and suggests considering specialized training centers.
15. Miller, MH: Psychiatric training for foreign medical graduates: a symposium: the foreign resident as a disappointed person. Psychiatry 1971; 34:252–256
This article addresses the situation of IMGs who have to return to their home countries at the end of a course of study in the United States. The potential cultural irrelevance of U.S. education for the departing IMG is discussed. It is suggested that special training sites may be useful.
Workforce
This section focuses on workforce issues for IMGs in psychiatry.
1. Rao NR: Recent trends in psychiatry residency workforce with special reference to IMGs. Acad Psychiatry 2003; 27:269–276
This study evaluates the extent to which the predicted downsizing of psychiatry residency training programs actually occurred and how it affected training programs of different sizes and locations. The result was a significant decline in the number of residents during the years studied, and IMGs found broad acceptance in training programs of all locations and sizes. The conclusion was that the field would have to decide whether it could afford any more residency downsizing in light of emerging evidence of a shortage of psychiatrists.
2. Rao NR: Psychiatric workforce: past legacies, current dilemmas, and future prospects. Acad Psychiatry 2003; 27:238–240
One major preoccupation in the psychiatric workforce in the past three decades has been how to increase USMGs’ interest in psychiatry. IMGs were used mainly to fill shortages. However, in the context of changes in health care, one has to reexamine the place of IMGs in the workforce and accept them fully.
3. Milne D: IMGs have played critical role in history of U.S. psychiatry. Psychiatr News 2002; 37:18–44
IMGs as a group have the potential to infuse the stream of American psychiatry with universal values and make important contributions to psychiatric education and research. However, changes in certain laws and licensing requirements affecting them may adversely affect their future.
4. Wood J, Marginson F, Allen D: Workforce planning: of one mind. Health Serv J 2001; 111:26–27
The National Health Service (NHS) is heavily reliant on locum doctors, many of whom train overseas. A pilot nine-session course for consultant locum psychiatrists was successful. Medical directors have expressed willingness to pay for such training. This article illustrates the success of the pilot project and possible funding for such initiatives.
5. Blanco C, Carvalho C, Olfson M: Practice patterns of international and U.S. medical graduate psychiatrists. Am J Psychiatry 1999; 156:445–450
Patterns of IMG and USMG psychiatrists were compared, using data from the 1996 National Survey of Psychiatric Practice. The authors compared IMGs and USMGs in terms of demographic characteristics, practice settings, patients’ clinical characteristics, and sources of reimbursement. The IMGs surveyed tended to be older than USMGs, included a higher proportion of women, and were more racially heterogeneous. They worked longer hours, worked more frequently in the public sector, and treated a higher proportion of patients with psychotic disorders. The IMGs also received a higher percentage of their income from Medicaid and Medicare than USMGs, whereas the reverse was true of self-payment. Pay sources may adversely affect the availability of psychiatrists to treat minorities and other underserved populations.
6. Rao NR, Meinzer A, Manley M, et al: International medical students’ career choice, attitudes toward psychiatry, and emigration to the United States: examples from India and Zimbabwe. Acad Psychiatry 1998; 22:117–126
The selection of residents who are IMGs can be facilitated by knowledge of the context of their training and experience in psychiatry, the career opportunities in the country from which they come, and their attitudes toward psychiatry, medicine and the United States. This study examines some of these variables, as well as the emigration plan of 209 Indian and 46 Zimbabwean medical students in their next-to-last year of medical school. Fifty-six percent of Indian students indicated that they had at least thought about emigrating to the United States for postgraduate training, and 22% had definite plans. Only 25% of Zimbabwean students had thoughts about U.S emigration, and a mere 2% had plans.
7. Zarin DA, Pincus HA, Peterson BD, et al: Characterizing psychiatry with findings from the 1996 National Survey of Psychiatric Practice. Am J Psychiatry 1998; 155:397–404
This article notes that 21.4% of APA members are IMGs and that IMGs were 21.5% of psychiatry residents in 1990, 35.4% in 1995, and were estimated to be nearly 50% in 1996.
8. Rao NR, Meinzer AE, Berman SS: Perspectives on screening and interviewing IMGs for psychiatry residency training programs. Acad Psychiatry 1994; 18:178–188
Acknowledging the varied educational and cultural backgrounds of IMGs, the authors share their experiences in screening and interviewing this pool of residency applicants and offer useful practical guidelines for interviewing. Appropriateness of applicants' fit to programs is also discussed.
9. Rao NR, Meinzer AE, Primavera LH, et al: Psychiatry residency selection criteria for American and foreign medical graduates: a comparative study. Acad Psychiatry 1991; 15:69–79
This article describes a survey of training directors to determine differences in criteria for assessing foreign medical graduates and American medical graduates. Exam scores were marginally more important for foreign medical graduates, while transcripts and reference letters were marginally more important for American medical graduates.
10. Weintraub W, Book J: Recruitment of public psychiatrists: the impact of university and state collaboration on FMGs in Maryland. Hosp Community Psychiatry 1986; 37:1017–1021
In Maryland, a joint initiative of the State University and the mental hygiene administration, called the Maryland plan, has been successful in attracting university trained psychiatrists, mainly USMGs, to public hospitals, leaving fewer training and employment opportunities for IMGs. The authors of the article predict that few IMGs will be able to compete with USMGs for residency slots, and they call for continued recruitment of the most qualified IMGs into the public system.
Education and Training
This section focuses on education and training issues of IMGs in psychiatry.
1. Kramer M: Educational challenges of international medical graduates in psychiatric residencies. J Am Acad Psychoanal Dyn Psychiatry 2006; 34:163–171
Suggestions are made on how to address IMGs’ educational needs. Specifics include more structured instruction, demonstration of interviewing by faculty, more opportunity to do practice interviews, language training, accent reduction, courses in American culture, an increased emphasis on psychological training early in residency, and mentorship. The specifics of the recommendations make this a valuable addition to the body of literature.
2. Kramer M: Educational needs of international medical graduates in psychiatry. Acad Psychiatry 2005; 29:322–324
This communication describes the current state of IMGs in the United States. It suggests improvements and adaptations to educational and training models to facilitate IMGs becoming competent psychiatrists. It is the author’s contention that such changes account for the high pass rate in Part 2 of the ABPN exams at one residency program.
3. Rao NR: International medical graduates, in Handbook of Psychiatric Education and Faculty Development. Arlington, Va, American Psychiatric Publishing, 1999, pp 125–141
This article reviews the history of problems IMGs have had entering the United States for training, the issues facing IMGs seeking a residency position and the learning problems that IMGs encounter in training and acculturation to the United States. The training implications of the problems and possible solutions are offered, and the factors affecting careers are addressed.
4. Weintraub W: International medical graduates as psychiatric residents: one training director’s experience, in International Medical Graduates in Psychiatry in the United States: Challenges and Opportunities (Issues in Psychiatry). Washington, DC, American Psychiatric Press, 1997, pp 53–64
The author addresses misconceptions about the performance of IMGs as psychiatry residents, reviews evidence for misconceptions, and attempts a more balanced perspective.
5. Ruskin R: Issues in psychotherapy supervision when participants are from different cultures, in Clinical Perspectives on Psychotherapy Supervision. Washington, DC, American Psychiatric Press, 1994, pp 53–72
Bearing in mind the importance of ethnocultural backgrounds, this article addresses the potential difficulties when supervisor, supervisee, and patient are from different backgrounds. There is an increased likelihood of problems in the supervisory relationship if these differences are not addressed. A useful article with supporting case material.
6. Muñoz RA, Madigan M: Graduates of foreign medical schools in American psychiatry. Hosp Community Psychiatry 1987; 37:1021–1024
A description of the face of American psychiatry in the mid-1980s with suggestions for improving the integration of foreign medical graduates.
7. Oliver N, Fingas W: The teaching of psychotherapy to foreign medical graduate residents in psychiatry. Psychiatr J Univ Ott 1986; 11:223–227
This article addresses foreign medical graduate training in general psychiatry in Canada and identifies problem areas in IMG training. The article notes, however, that specific remedial actions are lacking. The authors discuss their program’s strategies in teaching psychotherapy to FMGs. This article is important because it offers specific approaches to teaching psychotherapy to IMGs, an often neglected area.
8. Chen R: Foreign Medical Graduates in Psychiatry: Issues and Problems. New York, Human Sciences Press, 1981
A classic work on the problems of IMGs in psychiatry residencies, this NIMH-supported study was performed at seven sites between 1973 and 1976 and attempted to define areas of importance for assisting IMG adjustment and learning and evaluating the effectiveness of the methods used. The work is based on 64 questionnaires filled out by the participants and a series of papers written by the directors of the various programs. The focus is not curricular but is directed at aspects of acculturation, language problems, exploitation, and the problems of identity change and diffusion.
9. Weiss JM, Davis D: Predicting success in psychiatric training for foreign medical graduates: II: patterns in course. Psychol Med 1977; 7:311–316
Faculty ratings of 22 foreign medical graduates, all of whom entered psychiatry residency training at the University of Missouri-Columbia from 1966 through 1973, were compared with those of a similar group of North American medical graduates. Results indicate that in most areas of performance the median FMG started at a level substantially lower than that of the median American medical graduate and very slowly caught up.
10. Knoff WF, Oken D, Prevost JA: Meeting training needs of foreign psychiatric residents in state hospitals. Hosp Community Psychiatry 1976; 27:35–37
The authors recommend a more structured form of instruction, more presentations, more demonstrations, and more supervision. Courses in American culture, English language, and problem-solving techniques are discussed.
11. Lin T: Psychiatric training for foreign medical graduates: a symposium: VI: conclusion. Psychiatry 1971; 34:256–257
The goals of training FMGs should be understanding their life adjustment problems, identifying areas of psychiatry that are hard for them to learn, and formulating strategies to assist their accomplishment of educational objectives.
12. Brody EB, Modarressi TM, Penna M, et al: Intellectual and emotional problems of foreign residents learning psychiatric theory and practice. Psychiatry 1971; 34:238–247
This is an excellent article with clear examples reviewing issues for FMGs. It points out their similarities to American doctors, problems of migration, various cognitive affective styles of residents, issues related to independence, difficulties learning milieu therapy, problems related to family, social isolation and the elderly, and language difficulties.
13. Mittel NS: Training psychiatrists from developing nations. Am J Psychiatry 1970; 126:1143–1149
The author delineates three broad problem areas that profoundly affect the education of foreign psychiatry residents: differences in languages and cultural backgrounds, identity crisis, and the inability of the residency program to understand the needs of the foreign resident.
Discrimination
This section includes articles that address the perennial issue of discrimination against IMGs in psychiatry.
1. Reid WH, Durgam SK: International medical graduates as forensic experts. J Psychiatr Pract 2004; 10:130–133
Rather than assessing IMGs’ actual qualifications, this study assesses the attitudes of other forensic psychiatrists to IMGs. The mechanism used was a survey, and of those who responded, some forensic psychiatrists and trainees reported that IMG status adversely affected their career opportunities and competence. This article is useful in its direct assessment of aspects of discrimination against IMGs in a highly specialized field.
2. Norton J: Buy American: choosing psychiatry residents. Acad Psychiatry 2001; 25:181–183
This letter to the editor highlights some of the major issues inherent in choosing and training IMGs as psychiatry residents. It is an honest appraisal of the value of IMGs/USMGs as trainees. Institutionalized discrimination against choosing IMGs as residents is described. It recommends reaching out to the resident in informal and social situations and providing a very structured program to ensure a more productive outcome.
3. Balon R, Mufti R, Williams W, et al: Possible discrimination in recruitment of psychiatry residents? Am J Psychiatry 1997; 154:1608–1609
The authors sought to determine whether there is a selection bias against international medical graduate applicants for U.S. residency training positions in psychiatry. They conclude that some residency programs in psychiatry are attempting to limit the influx of IMG applicants at the very first level: the request for an application form. The reasons for this practice are not known, but discrimination could be a possible explanation.
Quality and Competence
Concerns about the quality of IMGs are a recurring theme in all of the categories. This section focuses on articles that address these issues specifically. It is useful to reemphasize the need for more systematic studies of IMG competence and quality in order to delineate better educational strategies and lay to rest familiar stereotypes. Though there are papers that address the quality of IMGs as a whole, there is a paucity of scholarly work pertaining to the quality of IMGs in psychiatry.
1. Val E, Quick S: Foreign medical graduates and board certification: myths and realities. Am J Psychiatry 1983; 140:184–188
Results of a survey on American Board of Psychiatry and Neurology certification were used to compare 503 FMGs and 2,332 USMGs on several variables: demographic characteristics, attitudes toward certification, performance, and personal experience with the examination. FMGs were more similar than dissimilar to USMGs.
2. Torrey F: Cheap labor from poor nations. Am J Psychiatry 1973; 130:428–434
In the author’s opinion, one of the most serious problems facing American psychiatry is the importation of large numbers of foreign medical graduates to staff the country’s mental hospitals. This article reviews the magnitude of the problem, the utilization of these doctors as "cheap labor," the quality of care provided, and the effects of the "brain drain" on the countries of origin. It discusses possible roots of the problem and suggests some solutions: functional job analysis, public service, accreditation, improved training abroad, separation of training and service, specialized training programs, and changes in immigration laws.
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Bibliography of Non-Psychiatric Literature on IMGs
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Acculturation
1. Hall P, Keely E, Dojeiji S, et al: Communication skills, cultural challenges and individual support: challenges of international medical graduates in a Canadian health care environment. Med Teach 2004; 26:120–125, comment in 101–105
This Canadian article describes a needs assessment designed to assess IMGs’ communication skill needs. Multiple information sources were utilized. Specific recommendations included English language skills; how to get things done in a hospital/health care system; opportunities to practice specific skills; an adequate support system; and faculty and staff education. The utilization of multiple information sources and the presentation of specific recommendations make this article an extremely useful addition from the international body of literature on IMG issues. Recommendations seem applicable to U.S. health care as well.
2. Horvath K, Coluccio G, Foy H: A program for successful integration of international medical graduates (IMGs) into U.S. surgical residency training. Curr Surg 2004; 61:492–498
This article describes a program that has successfully integrated residents into a surgical residency. It involved an intensive 8-week pre-residency clinical orientation, with didactic instruction, cultural integration, and a score-based prediction of future performance in surgical residency. It provided participants with enough experience to successfully integrate into a U.S. residency and identified those with better chances of success as surgery residents. Anecdotal reports suggest that such programs exist in psychiatry as well. However, the field needs documentation of such successful programs.
3. Srivastava R: On being a doctor: a foreign concept. Ann Intern Med 2004; 140:1057–1058
Interference in the performance of an IMG physician because of concern about the family left behind. It invites a greater sensitivity on the part of supervisors to the personal circumstance of the resident.
4. Fiscella K: Overcoming cultural barriers: IMGs in the United States. JAMA 2000; 283:1751
Medical educators need to take into account cultural differences when training IMGs for practice in the United States. Tools such as mixed IMG and USMG support groups, international student retreats, cultural sensitivity training, and standardized patients, may be helpful in achieving this goal.
5. Van Zanten M, Boulet JR, McKinley DW, et al: Evaluating the spoken English proficiency of graduates of foreign medical schools: detecting threats to the validity of standardized patient ratings. Med Educ 2003; 37:69–76
This study of over 2,500 candidates done by the Educational Commission for Foreign Medical Graduates (ECFMG) of English proficiency in the Clinical Skills Assessment (CSA) exam as rated by standardized patients. Proficiency in spoken English was related to native language (English versus other) and scores from the Test of English as a Foreign Language (TOEFL). Trained standardized patients were found to be a valid means of assessing candidates’ English proficiency.
6. Gaviria M, Wintrob R: Latin American medical graduates: II: the readaptation process for those who return home. Hisp J Behav Sci 1982; 4:367–379
Part of a study of FMGs from Peru, this report examines the determinants of the decision to return, problems during readjustment, and the effect of these U.S.-trained doctors on health care services in their home country.
Workforce
Included in the following are articles about how some major nonpsychiatric disciplines are contending with the issue of international medical graduates in their workforce.
1. Rao NR, Rao KR, Cooper R: Indian medical students’ views on immigration for training and practice. Acad Med 2006; 81:185–188
The authors surveyed final-year medical students in two Indian medical schools regarding their views on migration to the United States and other countries. They report that the United Kingdom has replaced the United States as a popular destination for Indian students. Nevertheless, significant numbers of Indian medical students continue to be interested in the United States as a location for their medical education and practice.
2. Mullan F: Doctors for the world: Indian physician emigration: greater self-sufficiency in recipient nations might allow India to focus medical education on domestic health care needs. Health Aff 2006; 25:380–392
This substantial document addresses the unique issue of the Indian physician workforce. With nearly 60,000 physicians practicing in the United States, United Kingdom, Canada, and Australia, India has the largest émigré physician workforce in the world. The author traveled to India and conducted interviews with leaders in medical education, health policy, and public health. The data from this journalistic endeavor are presented in this article and address such concepts as "brain drain," economics, health care provision to the poor, private sector health care, emigration, and resettling. Policy options are presented, both for India and recipient nations. For India, these include investment in the public sector and primary care, a moratorium on new medical colleges, maintaining affordable medical school tuition, legal/regulatory reform, and supporting the internal economy. On the recipient nation side, these include increased self-sufficiency, competitive study programs, and bilateral short-term training. This article highlights the tremendous subsidy to developed-world health care provided by the developing world. The developing world can ill-afford this in the context of attempting to improve its own stock. The policy recommendations are sound, and policymakers would do well to heed them.
3. Astor A, Akhtar T, Matallana MA, et al: Physician migration: views from professionals in Colombia, Nigeria, India, Pakistan and the Philippines. Soc Sci Med 2005; 61:2492–2500
In an attempt to delineate core issues related to physician migration from developing to developed countries, a questionnaire was designed and administered. An underlying theme for migrant physicians was a quest for improved economic and social prospects. The majority view was that physicians in developing countries were unable to fully utilize their skills. Responses varied concerning needs for educational reform or overall physician depletion in developing countries, but there was a consensus that physician shortages did occur in developing country public sector and rural health care facilities. Suggestions for decreasing developing countries’ physician drain include improving physician salaries and working conditions and developing bilateral cooperation with wealthier nations.
4. Nuchprayoon I: Thai medical graduates in the United States residency training programs: 1988–2003. J Med Assoc Thai 2005; 88:593–600
An enumeration and categorization of Thai medical graduates in U.S. residency training programs between 1988 and 2003. Thai medical students graduate with degrees in internal medicine and pediatrics, with fewer in psychiatry, surgery, neurology, and other specialties. Thais were clustered in a few residency programs, and most chose to pursue subspecialty training post-residency. Though general IMG trends are often commented on in the literature and majority IMG groups (e.g., South Asian) are often described, this article gives useful information on a minority group within the IMG community.
5. Sandhu DP: Current dilemmas in overseas doctors’ training. Postgrad Med J 2005; 81:79–82
This review article presents facts and figures concerning IMG training in the United Kingdom. IMGs comprise 30% of the NHS workforce. In 2003, 15,549 doctors joined the medical register, of which 9,336 were non-European Economic Area citizens. The NHS will, for some time, continue to rely on IMGs.
Parallels can be drawn between U.K. and U.S. experiences with IMG workforces, and this review is useful in demonstrating the continued importance of IMGs in the health care system.
6. Mayer ML, Preisser JS: The changing composition of the pediatric medical subspecialty workforce. Pediatrics 2005; 116:833–840
The distribution of women and IMGs across pediatric medical subspecialties was analyzed. Data sets included the American Board of Pediatrics board certification data and the 2002 American Medical Association Physician Masterfile. Of 16 pediatric medical subspecialties, percentages of IMG board certification rates were significantly lower in six. Endocrinology and gastroenterology remained dependent on IMGs. This article provides useful subspecialty information about IMGs.
7. Andriole DA, Klingensmith ME, Schechtman KB: Diversity in general surgery: a period of progress. Curr Surg 2005; 62:423–428
An analysis of the change of workforce demographics in general surgery residency training programs over the period 1996 to 2002. Declining interest among USMGs led to an increasingly diverse complement of general surgery residents. This was seen as progress towards achieving a resident physician workforce "more equitably representative of the racial and gender composition" of the larger society. This is an interesting quantitative analysis of the effects of waning USMG interest in this specialty.
8. Mullan F: The metrics of the physician brain drain. N Engl J Med 2005; 353:1810–1818
The author provides a detailed review of the dynamics of IMG migration to the four principal English-speaking countries. He discusses issues relevant to the donor as well as the recipient countries.
9. Carlier N, Carlier M, Bisset G: Orientation of IMGs: a rural evaluation. Aust Fam Physician 2005; 34:485–487
This is an article from Australia dealing with retention of foreign doctors in the rural workforce and their beneficial presence due to familiarity with these communities. The initial orientation of these foreign doctors was seen as a crucial point. This article points to the crucial role played by IMGs in the rural health care of many English-speaking countries.
10. Kostis JB, Ahmad B: International medical graduates and the cardiology workforce. J Am Coll Cardiol 2004; 44:1172–1174
Recent publications have expressed the view that there is a shortage of cardiologists which continues to worsen. An increase in the number of IMGs who enter cardiology practice has been proposed as a remedy for a projected shortage. The IMGs have to overcome challenges, including clinical practice, language proficiency, and cultural differences before they are incorporated into the fabric of U.S. cardiology.
11. Sullivan EA, Wilcock S, Ardzejewska K, et al: A preemployment program for overseas-trained doctors entering the Australian workforce, 1997–1999. Med Educ 2003; 36:614–621
Overseas-trained doctors (OTDs) have limited access to and formal interaction with the Australian health care system prior to joining the Australian medical workforce. OTDs who passed their Australian medical council examinations were invited to participate in a voluntary, free, 4-week, full-time program with a curriculum focusing on communication and acculturation issues. Participants reported a more realistic understanding of their role, the need for separation of workplace and personal responsibilities, and knowledge of pathways for future professional development. The program improved OTD integration into the workplace. This is a useful article on the real-world benefits of orientation and acculturation programs.
12. Baer LD: A proposed framework for analyzing the potential replacement of international medical graduates. Health Policy 2003; 9:291–304
There has been sentiment against IMGs that could lead to a reduction in their future supply within the United States. In this study, an analytical framework is proposed to illustrate the many issues that need to be considered in replacing IMGs in rural, needy areas. An IMG cutback, regardless of whether it is partial or comprehensive, would entail a twofold risk: policy makers would be gambling with access to health care in small towns and the possibility of promoting a fear of foreigners in the United States.
13. Newton DA, Grayson MS: Trends in career choice by U.S. medical school graduates. JAMA 2003; 290:1179–1182
Trends in career choice among specialties have varied greatly. Most notable is the recent decrease in the percentage of U.S. medical graduates choosing a primary care career, which has important implications for the U.S. physician work force. Though it was beyond the scope of this article to track the trends in career choice by IMGs, it recognized that IMGs fill more than 25% of all U.S. residency positions and provide a significant proportion of U.S. health care.
14. Brotherton SE, Rockey PH, Etzel SI: U.S. graduate medical education, 2002–2003. JAMA 2003; 290:1197–1202
This article gives statistical data on IMGs in graduate medical educational programs in the United States. Data are updated annually in the educational issue of the Journal of the American Medical Association.
15. Hagopian A, Matthew J, Thompson EK, et al: Health departments’ use of international medical graduates in physician shortage areas. Health Aff 2003; 22:241–249
This article addresses the J-1 visa program, working conditions in physician shortage areas, and the reliance on IMGs to make up for physician short supply. Employers seem to be more satisfied than physicians.
16. Hallock JA, Stephen SS, Norcini JJ: The international medical graduate pipeline. Health Aff 2003; 22:94–96
This perspective on global physician migration presents information from the Educational Commission for Foreign Medical Graduates (ECFMG) on the certification and practice of IMGs. Recommendations are made concerning workforce policies.
17. Whelan GP, Gary NE, Kostis J, et al: The changing pool of international medical graduates seeking certification training in U.S. graduate medical education programs. JAMA 2002; 288:1079–1084
This article reports that the number of IMGs seeking certification has gone down but the quality has gone up as reflected in Clinical Skills Assessment scores. This is a useful study that addresses the concern that the CSA examination has adversely affected the availability of IMGs.
18. Salsberg ES, Forte GJ: Trends in the physician workforce, 1980–2000. Health Aff 2002; 21:165–173
This article addresses physician workforce trends over the past 25 years. Contentious issues, such as the appropriate number of physicians needed, the role of IMGs, and primary care versus specialization, are also addressed.
19. Cooper RA, Getzen TE, McKee HJ, et al: Economic and demographic trends signal an impending physician shortage. Health Aff 2002; 21:140–154
A new model for workforce planning based on such indicators as economic expansion, population growth, physicians’ work effort and services from nonphysician clinicians is used to predict a physician shortage in the future. This article challenges past predictions of physician surpluses and encourages dialogue to address these challenges.
20. Eckhert NL: The global pipeline: too narrow, too wide or just right? Med Educ 2002; 36:606–613
A description of physician output of the world’s medical schools and comparison of physician-to-patient ratios, as well as other demographic analyses, are incorporated in this article. It places emphasis on means of tracking medical education globally and utilizing international collaboration.
21. Weissman J: Residents’ preferences and preparation for caring for underserved populations. J Urban Health 2001; 78:535–549
The objectives of this study were to describe preferences of resident physicians to locate in underserved areas and to assess their preparedness to provide service to low-income populations. 2,626 residents responded. Only one-third of residents rated public hospitals as desirable settings. Desirability was not associated with having trained in a public hospital or having greater exposure to underserved populations. Only about one-quarter of respondents ranked rural or poor inner-city areas as desirable. Men and noncitizen IMGs were more likely than others to prefer rural settings. Women, noncitizen IMGs, and especially underrepresented minorities were more likely to find inner cities desirable. This study attests to the important "safety net" role played by IMG physicians.
22. Mick SS, Lee S, Wodchis WP: Variations in geographical distribution of foreign and domestically trained physicians in the United States: "safety nets" or "surplus exacerbation"? Soc Sci Med 2000; 50:185–202
In the United States, a debate has existed for decades about whether IMGs and USMGs have been differentially distributed, such that IMGs were more likely to be found in locales characterized as high in need or medically under-serviced. This article shows that there were consistently more states having IMG disproportions than USMG disproportions. The magnitude of the differences was greater for IMGs than for USMGs, and there was a correlation between IMG disproportions and low doctor/100,000 population ratios. These findings are shown to exist simultaneously with two empirical facts: first, not all IMGs were located in new or underserved counties; second, IMGs were more likely than USMGs to be located in states with a large number of physicians. The juxtaposition of an IMG presence in "safety net" locales and of IMGs’ contribution to a physician abundance is discussed within the context of the current debate about a U.S. physician "surplus" and initiatives to reduce the number of IMGs in residency training.
23. Barondess J: Specialization and the physician workforce. JAMA 2000; 284:1299–1301
The author talks about the primary drivers of the trend to subspecialization. He states in this article that IMGs are more likely than USMGs to become subspecialists.
24. Aronson R: National interest waiver eligibility for international medical graduates. JAMA 2000; 283:1747
The author explains that national interest J-1 waivers do not create an unqualified entitlement to permanent resident status, as foreign physicians must fulfill a 5-year service commitment to a medically underserved area prior to obtaining permanent residency.
25. Salsberg E: The post-training plans of IMGs and U.S. medical graduates in New York State. JAMA 2000; 283:1749–1750
IMGs holding temporary visas are more likely than other IMGs to practice in health profession shortage areas. Given the higher proportion of IMGs with temporary visas who plan to specialize or to return to their native country after completing their primary care training, the contribution to primary care in underserved areas is not as dramatic as was previously thought.
26. Mick SS, Lee SY: Are there need-based geographical differences between international medical graduates and U.S. medical graduates in rural U.S. counties? J Rural Health 1999; 15:26–43
This article compares the rural location of IMGs and USMGs by specialty (primary care versus specialty care) according to geographical measures of need. Data from the AMA 1997 Physician Masterfile and the 1996 Area Resource File (Bureau of Health Professions) were used. Need-related factors included high infant mortality, low socioeconomic status, high proportion of the nonwhite population, high proportion of the elderly population, and low physician-to-population ratio. IMGs were disproportionately represented in rural counties. Regionally, these disproportions tended to be in the central and south census regions. Disproportions of specialty care IMGs were greater than those of primary care IMGs. However, results varied considerably between states. It was concluded that proposed limits on IMG entry into residency training may create health care access problems in rural areas. State-by-state assessments were recommended. This provides a very useful data analysis, pointing to how multifactorial and regionally specific IMG issues can become and reaffirming the "safety net" role of IMGs in the U.S. physician workforce.
27. Mick SS, Lee SY: International and U.S. medical graduates in U.S. cities. J Urban Health 1999; 76:481–496
An analysis of the comparative distribution of post-resident IMGs and USMGs in high and low poverty areas of U.S. cities. Data from the 1997 AMA Physician Masterfile and 1990 U.S. Census were merged to categorize physicians’ practices as being in low or high poverty areas in selected U.S. cities. The results showed that a statistically significant disproportion of IMGs relative to poverty was more common in larger cities. This is a useful analysis of urban physician workforce patterns.
28. Hagopian A, Thompson MJ, Kaltenbach E, et al: The role of international medical graduates in America’s small rural critical access hospitals. J Rural Health. 2004; 20:52–58
A telephone survey was conducted on CEOs of critical access hospitals (CAHs) concerning their use of IMGs and the characteristics of these IMGs in the winter of 2002. There was a 96% response rate. Overall, 24% of admitting physicians in CAHs were IMGs. The rate is higher for CAHs in persistent poverty counties, CAHs that report recruitment problems, and CAHs with smaller medical staffs. Hospitals in the east required more IMGs than hospitals in the west. The majority of IMGs were internists (59%), and most came from India, the Philippines, or Pakistan. Clinical skills of IMGs were rated highly, and interpersonal skills slightly lower. Almost half of CAH administrators recruited their first IMGs during or after 1994. This is significant because of pro-IMG legislative changes during this time. The study concluded that IMGs play a significant role in staffing CAHs and is a well-focused study pointing out workforce trends.
29. Baer LD, Ricketts TC, Konrad TR, et al: Do international medical graduates reduce rural physician shortages? Med Care 1998; 36:1534–1544
A central IMG issue is whether IMGs, in compensating for local physician shortages, potentially exacerbate a national oversupply. Data from the American Medical Association Physician Masterfile and the Bureau of Health Professions’ Area Resource File were used to calculate the percentage of IMGs in rural primary care settings. IMGs do make up a greater percentage of physicians in rural areas with physician shortages than in rural areas without physician shortages. The finding was consistent at the national, census region, and state levels, but to varying degrees. Particularly at the interstate level, there is considerable variation, suggesting other factors may be involved. Further research is necessary to clarify this. This provides a very useful data analysis, pointing to how multifactorial and regionally specific IMG issues can become.
30. Aranha GV: The international medical graduate in U.S. academic general surgery. Arch Surg 1998; 133:130–133
IMGs account for 10% of the academic surgical faculty in the United States. Their positions are commensurate with their experience. Since 1960, there have been an increasing number of appointments of IMGs to faculty in departments of surgery. The results of the survey suggest that the experience of IMGs in U.S. surgery has been quite favorable.
31. Mick SS: The safety-net role of IMGs. Health Aff 1997; 16:141–150
Efforts to restrain physician supply could undo the migration of IMGs to locales that U.S.-trained physicians often ignore. The author raises issues related to IMGs, their number, graduate medical education (GME) reimbursement, and the 110% solution.
32. Iglehart JK: The quandary over graduates of foreign medical schools in the U.S. N Engl J Med 1996; 334:1679–1683
American reliance on IMGs represents a quandary for Congress, particularly the Republican members who have misgivings about government intervention and believe strongly in private markets. Paradoxically, while U.S. residency programs accommodate an increasing number of IMGs, record numbers of American students applying to domestic medical schools are denied admission because of the concern that too many doctors are already being trained.
33. Kindig DA, Libby DL: Domestic production versus international immigration—options for the U.S. workforce. JAMA 1996; 276:978–982
A demographic production model of physician supply was used to predict future physician supply in the context of future physician-to-population ratios. The slow rate of physician attrition is an important consideration in the analysis. It recommends reduction in future physician supply by reduction of IMG or USMG numbers, or both.
34. Mullan F: Medical migration and the physician workforce: IMGs and American medicine. JAMA 1995; 273:1521–1527
In recent years, participation of IMGs in GME and practice has increased significantly. Most IMGs in GME are not exchange visitors but are either permanent residents or U.S. citizens. Patterns of specialization and locations of IMGs ultimately mirror those of USMGs. The best option for long-term control of the number of physicians in practice, USMG or IMG, is a system of specifying the number of GME positions nationally.
35. Lyttle C: The changing demographics of internal medicine residency training programs. Ann Intern Med 1994; 121:435–441
More IMGs are joining internal medicine residency programs. The increase in the percentage of IMGs, as well as their tendency to subspecialize to a greater degree than USMGs, will affect the efforts to increase the number of general internists.
36. Stevens R, Goodman L, Mick SS: The Alien Doctors: Foreign Medical Graduates in American Hospitals. New York, John Wiley and Sons, 1978
Truly the classic work on the education that IMGs were getting in 1973 and 1974. The authors point out the difference between being an apprentice or an assistant, the former being the preferred mode even today in residency education. Informal learning for IMGs needs to be encouraged. The learning milieu is crucial and residents need to be assisted in moving into the mainstream of medicine. A similar study of the actual training experience of IMGs in residencies needs to be done again.
37. Osteen A: Licensure and international medical graduates. JAMA 1991; 266:956–958
The author reviews the history, since 1988, and current status of licensing regulations for IMGs in the United States.
Education and Training
1. Boulet JR, Norcini JJ, Whelan GP, et al: The international medical graduate pipeline: recent trends in certification and residency training. Health Aff 2006; 25:469–477
IMGs represent a large proportion of the population entering graduate medical education. The Education Commission for Foreign Medical Graduates (ECFMG) certification, a prerequisite for GME, has varied over time and historically exceeded the number of available training positions. Further longitudinal analysis is necessary.
2. Norcini JJ, Boulet JR, Whelan GP, et al: Specialty board certification among U.S. citizen and non-U.S. citizen graduates of international medical schools. Acad Med 2005; 80:42–45
An analysis of whether USMGs and IMGs differed in specialty board certification, this article showed that they did. Overall, USMGs have the highest specialty certification rates, followed by non-USIMGs and USIMGs. Among recent graduates, non-USIMGs have rates comparable to USMGs. A good enumeration of current trends.
Discrimination
1. Coombs AA, King RK: Workplace discrimination: experiences of practicing physicians. J Natl Med Assoc 2005; 97:467–477
This study was a mail-in questionnaire-based survey of practicing physicians in Massachusetts concerning workplace discrimination. It was designed to describe the types of discrimination that exist and to determine which groups were more likely to experience them. The response rate was 24%. A large proportion of respondents were women, ethnic minorities, and IMGs. Over 60% of respondents believed discrimination against IMGs was very or somewhat significant. Of USMGs, 44% reported that discrimination against IMGs in their current organization was significant. Nonwhite respondents were more likely to report that discrimination based on race/ethnicity was significant. Nearly 29% of white respondents also believed that such discrimination was very or somewhat significant. Though this study suffered from a low response rate and carries the risk of respondent bias, it is a useful analysis of a complicated issue.
2. Dow WH, Harris DM: Exclusion of international medical graduates from federal health care programs. Med Care 2002; 40: 68–72
An interesting study of possible disparities in Medicare/Medicaid exclusion between USMGs and IMGs. A large number of physicians were studied (>80,000). IMGs were not considered as a single group but were divided into those from Organization for Economic Cooperation and Development (OECD) high-income countries and those from non-OECD countries. Board certification status was also considered. Non-OECD IMGs had a higher relative risk of exclusion. Never having been board-certified also conferred an increased relative risk. The paper did not draw firm conclusions about these disparities but suggested further research.
3. Moore RA, Rhodenbaugh EJ: The unkindest cut of all: are international medical school graduates subjected to discrimination by general surgery residency programs? Curr Surg 2002; 59:228–236
IMGs have been part of the United States residency applicant pool for several years. The purpose of this study was to find out if measurable discrimination against IMGs existed, real or perceived. Survey results indicate the perception that IMGs are similar in skill and ability to USMGs, regardless of program size. However, a perception existed among program directors that USMGs were favored in the recruitment process, with more than 70% of respondents indicating that they believed IMGs were discriminated against. Furthermore, nearly 20% reported that they had been pressured to rank a less-qualified USMG higher than a more qualified IMG, and 22% reported that they had ranked a USMG higher than an IMG to avoid a reduced complement of USMGs.
4. McDaniel P: Nonaccredited medical education in the United States. N Engl J Med 2000; 343:1120–1123
A series of eight letters to the editor are written in response to Kasselbaum and Cohen’s sounding board article (May 25, 2000) on nonaccredited medical education in the United States. The letters are refutations of the claims of the authors, defending the standards of overseas medical schools and criticizing domestic standards. They are met with a rebuttal by Dr. Kasselbaum. This collection is a useful nexus for observing the range of debate on issues of IMG quality and medical education policy in the United States.
5. Baldwin G: IMG report details academic discrimination. Am Med News, Dec. 21, 1998
IMGs are disproportionately underrepresented in medical academic departments' chair positions in the U.S. IMGs, who constitute nearly one-fourth of all U.S. physicians, hold only 12% of department chair positions. It is not related to a lack of qualifications; it is more a question of bias.
6. Memoun MA: The international medical graduate in U.S. academic general surgery: is the truth out? Arch Surg 1998; 133:781–782
The future of IMGs in academic surgery looks bleak. IMGs are still considered inferior to USMGs, and they continue to be used in positions not readily accepted by USMGs, such as preliminary positions and transplant surgery. In 1998, there were only nine IMGs who were surgery department chairpersons.
Quality and Competence
Questions about the competence of IMGs as physicians and their readiness to undergo GME training have always been a concern of the field. This section contains articles that address this issue in the broader context of American medicine.
1. Ko DT, Austin PC, Chan BT, et al: Quality of care of international and Canadian medical graduates in acute myocardial infarction. Arch Intern Med 2005; 165:458–463
A retrospective cohort study of linked administrative databases to answer quality-of-care questions concerning IMG management of acute myocardial infarction. Eight years' worth of records were analyzed. With 127,275 acute myocardial infarction patients admitted over this period, a comparison of outcome measures and secondary prevention showed no statistically significant difference between Canadian-medical-graduate-treated patients and IMG-treated patients. The results of this study refute the commonplace notion that IMGs provide inferior care.
2. Carderalli R, Lacciardone JC, Ramirez G: Predicting risk from actions by the state medical board. Tex Med 2004; 100:84–90
An average of 3,488 actions were brought against physicians in Texas each year from 1991 to 1999. IMGs, including Hispanic and Asian physicians, were less likely to receive disciplinary actions compared to male U.S. allopathic and white physicians. IMGs showed a decreased risk of disciplinary action for all violations, mostly in the alcohol or drug use category.
3. Lee S, Dowa WH, Wang V, et al: Use of deceptive tactics in physician practices: are there differences between international and U.S. medical graduates? Health Policy 2004; 67:257–264
Concerns have been raised about the medical practices of IMGs in the United States. This study examines the differences between IMGs and U.S.-trained medical graduates in their attitudes toward and utilization of deception in medical practices. IMGs and USMGs displayed limited differences in their attitudes but some differences in their self-reported use of deceptive tactics in medical practice. IMGs were less likely than USMGs to change the patient’s official diagnosis or to withhold a useful service because of utilization rules. The hypothesis that IMGs have less appropriate professional standards than USMGs is not supported by this study. Alternative hypotheses, such as IMG familiarity with U.S. health care and legal systems, warrant investigation.
4. Van Zenten M, Boulet JR, McKinley D, et al: Evaluating the spoken English proficiency of international medical graduates: detecting threats to the validity of standardized patient ratings. Med Educ 2003; 37:69–76
A retrospective study of 43,327 patient encounters during the ECFMG Clinical Skills Assessment (CSA) exam was undertaken. This involved over 5,000 candidates, 33% of whom reported English to be their native language, and over 100 standardized patients. Candidates’ spoken English proficiency was rated by standardized patients. Candidates’ mean English ratings were not associated with the native language of the standardized patient. Native English speakers achieved higher ratings. The results suggested that standardized patients provided unbiased English ratings.
5. Rothman AI, Cusimano M: Assessment of English proficiency in international medical graduates by physician examiners and standardized patients. Med Educ 2001; 35:762–766
A Canadian study to assess and compare the quality of ratings of oral English proficiency of IMGs provided by physician examiners and standardized patients. Seventy-three candidates for the Ontario International Medical Graduate Program were tested in an objective structured clinical examination (OSCE) format. Correlations between the physician and standardized patient ratings ranged from 0.52 to 0.70. Standardized patients provided more lenient ratings. Mean alpha reliability for the physicians’ ratings was 0.59 and for the standardized patients' ratings was 0.64. There was poor agreement between the two sets of raters in identifying problematic candidates. Useful in demonstrating the difficulty involved in rating IMGs.
6. Bates J, Andrew R: Untangling the roots of some IMGs’ poor academic performance. Acad Med 2001; 76:43–46
This article provides four descriptions of academic performance problems of IMG residents in a 2-year family medicine program. Components of an effective training approach for IMGs in primary residency programs are listed.
7. Whelan G: High stakes medical performance testing: the clinical skill assessment program. JAMA 2000; 283:1748
The implementation of the Clinical Skills Assessment (CSA) program in 1998 came as a result of a widespread concern among U.S. medical educators that basic clinical skills of IMGs were variable in quality. CSA was developed as a tool to assess their basic clinical skills. IMGs found it unfair that U.S. medical graduates were exempt from taking a similar examination.
8. Waxman HS: Workforce reform: IMGs and the in-training examination. Ann Intern Med 1997; 126:803–805
The performance of IMGs at all three levels of residency (internal medicine) on the in-training exam (ITE) are higher than those of USMGs and the gap is widening. Considering the need for IMGs and their abilities, as reflected by their performance in the ITE, a simplistic curtailment of the opportunities for thousands of IMGs to enter U.S. residency programs will be retrograde.
9. Fiscella K, Roman-Diaz M, Bee-Horng L, et al: Being a foreigner, I may be punished if I make a small mistake: assessing trans-cultural experiences in caring for patients. Fam Pract 1997; 14:112–116
Unrecognized emotionally charged issues provided problems for IMGs in caring for patients in a family practice residency. They used a resident write-up of a critical incident as a basis for a focus group. Residents, with a facilitator, identified struggles for acceptance, fear of rejection, fear of disappointing patients, and ways to express concern for patients. They made curricular changes as a result.
10. Morrison J, Wickersham P: Physicians disciplined by state medical boards. JAMA 1996; 279:1889–1893
This was a case-control study on publicly available data matching 375 disciplined physicians with two groups of control physicians, one matched solely by locale and the second by sex and type of practice. Findings included 30% of complaints being initiated against IMGs, who are not overrepresented as receiving more disciplinary action than USMGs in this sample.
11. Stevens RA: International medical education and the concept of quality: historical reflections. Acad Med 1995; 70(suppl 7):S11–S20
The author discusses cross-cultural issues in defining quality in medicine and in medical education; although some technical aspects of medicine span national boundaries, medical practice has a large cultural component. Tension is noted between forces favoring international standardization in medicine and forces favoring variations among cultures.
12. Carlson C: International medical education: common elements in divergent systems. JAMA 1991; 266:921–923
The author reports on a survey of aspects of medical education in 30 foreign countries compared with medical education in the United States. The survey covers graduation rates, percent of entering residencies, first choice of specialty, percent of funding by the government, and year of first patient contact.
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TOP
INTRODUCTION
Method
