Concurrent Sessions: Exploring Issues Relating to International Medical Graduates

The Educational Commission for Foreign Medical Graduates (ECFMG) 50th anniversary invitational conference, “Impact of International Medical Graduates on U.S. and Global Health Care,” brought together 218 participants, representing 24 countries. These participants brought expertise in a wide range of relevant fields, including physician workforce issues, accreditation, international medical education, cross-cultural issues in medicine, and assessment of physician competence. As well as attending presentations at the conference, the participants shared their expertise and ideas in concurrent small-group sessions on the following five topics: workforce and distribution, accreditation, improving international medical education, international medical graduates (IMGs) and the challenge of acculturation, and quality of IMGs. The set of concurrent sessions was presented twice in immediate succession, allowing each participant to take part in discussing two of the five topics. Each small-group session consisted of a brief presentation by the facilitator, followed by discussion by the other attendees. For some of the topics, the groups broke into subgroups, each of which then reported to the full group. Then at the plenary session that followed the concurrent small-group sessions, each facilitator summarized points made. It was noted that often the discussion was lively. Presented below are overviews of the concurrent small-group sessions on the five topics. In each, a synopsis of the facilitator’s opening presentation at the small-group session is followed by a summary of points raised in discussion. Session on Workforce and Distribution This session was facilitated by John R. Boulet, PhD, assistant vice president for research and evaluation, ECFMG, Philadelphia, Pennsylvania. The co-facilitators were Danette W. McKinley, PhD, research scientist, Foundation for Advancement of International Medical Education and Research (FAIMER), Philadelphia, Pennsylvania, and Richard A. Cooper, MD, professor of medicine, Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania. Presentation Dr. Boulet began this concurrent session by noting that in the United States, IMGs (graduates of medical schools outside the United States and Canada) constitute approximately 25% of the physician workforce and occupy approximately 25% of residency positions. He mentioned that shortages of physicians in the United States are projected and said the recommended increase in class size at U.S. medical schools will take several years to help allay this shortage. He thus concluded that the United States will continue to depend on IMGs for a substantial time. The rest of the presentation consisted largely of statistics on IMGs in the United States. Sources of data were ECFMG application information (regarding citizenship, medical school attended, and demographics) and the 2005 American Medical Association (AMA) Physician Masterfile (regarding practice, location, and training). Information included the following: Of professionally active physicians in the United States, excluding individuals aged 70 and older and residents, 477,369 are graduates of U.S. or Canadian allopathic medical schools (MDs), 42,258 are graduates of osteopathic medical schools (DOs), 27,771 are IMGs who were U.S. citizens upon entering medical school (USIMGs), 120,675 are IMGs who were not U.S. citizens upon entering medical school (non-USIMGs), and 2,344 are IMGs of unknown citizenship at the time of medical school attendance. Larger percentages of IMGs than of U.S. medical graduates occupy residency positions in internal medicine and family practice. The reverse is true for anesthesiology, obstetrics and gynecology, psychiatry, diagnostic radiology, emergency medicine, and orthopedic surgery. Among U.S. physicians other than residents, about 80% of graduates of U.S. medical schools identify patient care as their major professional activity. The corresponding figure slightly exceeds 90% for DOs and USIMGs, and it is nearly 90% for non-USIMGs. The percentage of active physicians who are in primary care is about 35% for allopathic physicians who graduated from U.S. medical schools, somewhat more than 50% for DOs, almost 50% for USIMGs, and almost 40% for non-USIMGs. IMGs are not evenly distributed among U.S. states. They constitute 30–40% of active physicians in New York, New Jersey, West Virginia, Illinois, and Florida. At the other extreme, they are less than 10% of active physicians in Vermont, Montana, Idaho, Wyoming, Utah, Colorado, Oregon, and Alaska. Regarding total numbers of IMGs who are active physicians: New York, Florida, and California each have more than 10,000; New Jersey, Pennsylvania, Ohio, Michigan, Illinois, and Texas each have 5,000 to 9,999. As the lower extreme, Maine, Vermont, and New Hampshire have fewer than 500 IMGs each, as do Alaska and Hawaii and a number of the less populous states in the West and upper Midwest. Of IMGs in the United States, 157,410 have completed residencies and are involved in patient care, 30,899 are residents, 7,908 are pursuing other professional activities, 19,833 are inactive, and 14,890 are not classified. Data also are available on where IMGs received their undergraduate medical education and on IMGs’ country of citizenship at the time of medical school. The greatest proportion of IMGs in the United States—somewhat more than 20%—attended medical school in India. The Philippines is a distant second, at about 8%. Next come Mexico, Pakistan, and the Dominican Republic. The next 10 countries in the list are Grenada, Egypt, South Korea, China, Dominica, Iran, Italy, Spain, Netherlands Antilles, and Syria. Of IMGs in the United States, slightly more than 20% were citizens of India at the time of medical school, and about 18% were U.S. citizens. Next come the Philippines, Pakistan, China, Iran, Korea, Egypt, the U.S.S.R., Syria, the United Kingdom, Cuba, Nigeria, Colombia, and Lebanon. The medical schools that have contributed the greatest numbers of IMGs are, in descending order, the Universidad Autónoma de Guadalajara (nearly 7,500 IMGs), University of Santo Tomas (about 7,000), St. George’s University (more than 5,000), Ross University (more than 4,000), and Dow Medical College (more than 3,000). Next on the list, at about 2,500 to 3,000 apiece, are the American University of the Caribbean, Far Eastern University–Nicanor Reyes Medical Foundation, University of the Philippines Manila, University of the East–Ramon Magsaysay Memorial Medical Center, and University of Damascus. Altogether, about 12,500 IMGs in the United States are from Africa. Of these, about 35% are from Egypt, 22% from Nigeria, 15% from South Africa, 6% from Ghana, 4% from Ethiopia, 4% from Kenya, and 14% from elsewhere. Overall, the number of ECFMG applications and the number of ECFMG certifications have been increasing since about the year 2000. Current numbers for each are about 10,000 per year. Discussion Participants in this session received four questions as starting points for discussion: In planning for the U.S. health workforce, how can we best utilize IMGs? Will the projected increase in the number of U.S.-trained physicians affect overall distribution and specialization? What is the future role of U.S.-citizen IMGs? Will physician migration patterns change in the future? During the discussion, which Dr. Boulet summarized at the plenary session, the following points emerged: Role of nonphysician health care providers. Physician assistants, nurses, and nurse practitioners contribute to the provision of health care, and therefore workforce models should include these professionals. However, given the number of services provided by these individuals, transferring responsibilities for patient care might not appreciably resolve physician shortages. Planning and distribution. The increase in output of U.S. medical schools must be accompanied by a corresponding increase in the number of residency positions available, especially in primary care specialties. Otherwise, IMGs could be forced out of the system, and shortages will persist. The U.S. government could continue to use immigration law to address shortages and geographic maldistribution of physicians. Need may exist for a single type of work visa, having service requirements, for all IMGs seeking graduate medical education. The increasing number of USIMGs applying for ECFMG certification suggests that the number of U.S. students who want to be doctors exceeds the number accepted to U.S. medical schools. It is reasonable to assume that, given increased enrollment at U.S. medical schools, many such individuals will attend medical school in the United States rather than elsewhere. This change may shift the composition of “off-shore” medical schools and of osteopathic medical schools. The quality of U.S. medical graduates could be affected as more places become available in U.S. medical schools. The role of osteopathic physicians should not be ignored in physician workforce planning. Cultural diversity and workforce planning. The United States has a culturally diverse patient population, and IMGs contribute helpful diversity to the physician workforce, through familiarity with patients’ cultures and native languages. If the proportion of U.S. citizens in the physician pool increases, cultural and linguistic needs of some patient groups might not be met as well as at present. Potential changes in physician migration. Globalization of medicine could result in U.S. physicians’ migrating to other countries to pursue specialty choices or other career interests. Although currently many internationally trained physicians want to pursue graduate medical education in the United States, this might not be so in the future. Changes in the numbers of IMG s arriving could affect the U.S. physician workforce. Brain drain. Developed nations have a responsibility to address issues of “brain drain.” Although the U.S. physician workforce has more than 150,000 active IMGs and is likely to gain more, most of these individuals come from a few countries and graduated from select medical schools. Many IMGs come from countries where the loss of health professionals has little impact on local populations. However, in some cases, especially those of African nations, emigration can profoundly impair the country’s ability to provide adequate health care. Session on Accreditation This session was facilitated by Frank A. Simon, MD, director of undergraduate medical education policy and standards, AMA, Chicago, Illinois, and member, Board of Trustees, ECFMG. The co-facilitator was Marta van Zanten, research associate, FAIMER, Philadelphia, Pennsylvania. Presentation Early in the presentation that opened this concurrent session, Dr. Simon differentiated accreditation from recognition. Accreditation, he stated, is a process of quality assurance. It is based on standards for process and outcomes; addresses functions, structure, and performance; and is designed to foster improvement in institutions and programs. Recognition attests to the authority to provide an educational program and grant a degree. He noted that the two terms or concepts are not clearly distinguished worldwide and, indeed, in some places are used interchangeably. Other main points in the presentation were the following: Accreditation entails an evaluation of education programs. The evaluation is conducted by an official authority, which may be either governmental or independent is to the The accreditation process standards, and Accreditation may be either or It is not a for of information about in many is not available about information is how it is and how the information is used to about The Foundation for Advancement of International Medical Education and Research (FAIMER), in by the ECFMG, is and a of international for each country in the is the of the authority and a to the relevant The not all with responsibilities to medical schools or medical education programs. Of the countries with medical schools in the International Medical Education a approximately have accreditation 10% have accreditation and have accreditation in the planning for the other it is unknown accreditation The countries to have accreditation include most of those with medical schools, most with schools that U.S. and some the Among countries with accreditation are the the the Philippines, South Korea, and the United In of the accreditation is in it is and in the other it is is Accreditation is by a government authority in of the countries and by an independent in for the it is not the is governmental or Among the countries with accreditation are Egypt, and countries accreditation have few medical schools. In some is a rather than of countries accreditation have Discussion Discussion at the session on several topics. The main points raised about each were as for was that should be an internationally accepted for The for accreditation should process and of standards are so that are for local set of standards should be to be than have been by several including the for Medical Education the on Medical the Institute for International Medical and the Accreditation for Education in and Other Health The standards use a with a for accreditation and a quality improvement to institutions of assessment of medical schools to be as educational accreditation is less in this for medical schools. the ECFMG could that for certification be graduates of medical schools by local During the discussion of this the was raised as to a graduate medical education could for an undergraduate medical education. of an international accreditation The most be quality of medical schools. of an international accreditation also help students to the quality of medical schools. In by to the quality of undergraduate medical education, such a the to International to the on this The of participants said such an should not as be from the educational process to be The an noted that should be in the of and rather than could be through either an international such as or the or through a such as the Health Eastern the or the of a to quality of international medical schools. a might to in the physician workforce medical schools to the standards were forced to In it might on the it could contribute to on the it could in It also might medical schools to the standards, thus improving medical education. of accreditation on who should have to data in the accreditation the to accreditation for many medical schools is and not to accreditation Session on International Medical Education This session was facilitated by John PhD, president and FAIMER, Philadelphia, Pennsylvania. The co-facilitator was MD, assistant vice president for education, Presentation Dr. opened this concurrent session by how could the education and the improvement of the health of populations. He of improving medical education by quality and policy and practice. He then presented the following of a of medical then and of medical education medical and thus Dr. said that has to on geographic in to have more impact and to be to more the of primary has been India and more South Other of are South and Africa. The of activities, Dr. is the a program for international medical in the per to Each must do a that has of or The should to improvement of health through of medical education. In their year as in the United States, on and the who will as their They then have of which they in and on their In the they two in the United States, about and the The with of which they work with those they are and on their The Institute which is based on needs on educational and on and The major of educational are and small-group including use of educational and and are program evaluation, change and The Institute evaluation through the University of New also has been In two at Medical College in and at Medical College in been with local and are These which are the are relevant and and they and of local of in India and in and South are participant in the session for of by Institute The given were on the following topics: the assessment system, and health It was noted that the for the must come from the local medical school. Discussion the participants in the concurrent session met in several of each were to each other about the have been best with a program and health and were they in this Then the each together to identify of and to how they could be to education a of each reported on main points At the plenary session, Dr. the Institute and He then summarized by at sessions with to the Institute in medical education to in These into four that of such a health to the for to an or a in and in that foster such as who are in and to a to and change and a of through and and provide for and of include not physicians also other health and have to on some of that for from the needs of the and that the is involved in medical schools and the and health on of the patient education and education. include health in needs to education and on and on data of for by on the and by to governmental and other that students to work in service to the through or in the of through students that to and increase of for Session on International Medical Graduates and the of This session was facilitated by MD, ECFMG, Philadelphia, Pennsylvania. The co-facilitator was ECFMG. Presentation Dr. began this concurrent session by as from to become and work and in He then the a and presented the following points from cross-cultural of the shared and among with a and It that have the to It is on from to the In the of Dr. then as doctors from cultures and with American He this with that of cultural in which American doctors to and with from He then that, of are such as American doctors and American doctors and other of other then that IMGs as especially These were and other of medical and Discussion the those at the session were into Each was of the and medical or For the the was to identify major issues, for and to Then for each of the subgroups, a presented a summary to the attending the In an at the plenary session, Dr. noted the concepts of cultural and He then noted in each of the He concluded by some and other of For of with to and other of can include and medical and and and individuals who the IMG Medical to medical a number of to In part patient is in the United States than in many other cross-cultural issues can the medicine is less in the United States than in of the rest of the for IMGs often must to the that they their ideas on and on Other cross-cultural issues include the role of the the of health care to the Health and or the of medical and other and In in medical can be from specialty to that IMGs include those to a and in and local and in American In it was noted that IMGs can of and of IMGs with must residencies in to in the United Cultural issues also family who are IMGs. Other must be a to are not for IMGs also for who The of issues are internationally physicians from to those cultures may The are they are given the migration of physicians. Session on of International Medical Graduates This session was facilitated by MD, president and American Board of Medical Illinois, and member, Board of Trustees, ECFMG. The co-facilitator was vice president for ECFMG, Philadelphia, Pennsylvania. Presentation In this concurrent session, Dr. reported that IMGs constitute about 25% of the U.S. physician workforce. He also noted that is a projected of physicians in the United States and that to this it has been recommended that class size at U.S. medical schools In he said that increasing numbers of USIMGs have been applying for ECFMG He raised the issues of how USIMGs and and how to the quality of individuals, and he participants to other than those he be in the quality of and of an undergraduate medical education can increase overall quality of IMGs. Dr. then presented the following can be through and include the United States Medical and certification include the by of residency by in of and of ECFMG certification is designed to provide that graduates of medical schools outside the United States and have met the standards to residency in the United States. of quality include to on of the and of help questions about quality of application data were from the ECFMG, and were for the The application data included year of and so certification was a residency was and the is in the Physician The number of USIMGs seeking certification has increased since the However, especially since about the percentage of USIMGs of the has been lower than that for from U.S. medical schools and also lower than that for non-USIMGs. the for those from U.S. medical schools has been 90% or and that for has been or slightly that for USIMGs has from about 50% to from about to percentages of USIMGs and of the have since For the most years for which are available, 90% for from U.S. medical schools, were 80% or slightly lower for and were approximately for However, for since have been somewhat for USIMGs than for with for USIMGs from about to 90% and for at 80% or slightly the of USIMGs than have been accepted to for since the have for graduates of U.S. medical they have from about to 80% for USIMGs and from slightly 50% to about for non-USIMGs. for USIMGs those for it that the may be It that among IMGs who their ECFMG at several years and thus are likely to have completed their the percentage of USIMGs in the Physician Masterfile has to somewhat the percentages of of than of USIMGs and U.S. medical school graduates work in Health Distribution among specialty U.S. medical school graduates and IMGs. The most with to internal medicine, the specialty of of USIMGs and of IMGs of of U.S. medical school Of physicians with internal medicine is the most specialty for all for U.S. medical internal medicine is the specialty of of the corresponding are for and for In of USIMGs, of U.S. medical and of are in family practice. The percentages for the groups for all in the range of to Discussion At the of the the following were for discussion: quality of needs for primary care, and provision of care to Other discussion included data and quality of data Although data been participants the for the of data that were to the for as a residency program director or a of a Among were information on based on medical school, and also was in more about the quality of the medical school from which the IMG about which information was included standards, and of Participants in the session for the in of USIMGs and non-USIMGs. was discussion of the pool of U.S. citizens attending international medical schools. were raised as to most of these individuals to U.S. medical schools, their and information about of this the and other to be a physician in the United States. were for more data about the international medical schools that graduate many USIMGs and for information about of accreditation or are available in the number of participants the of U.S. students attending medical schools in the It was noted that almost all of these students do their often in the United States or United were that these were in for such educational of a medical school that the education of USIMGs could be in the United States were more to USIMGs seeking Other the discussion, the was raised of of physician are based on or for physicians should be used more and other health care should take The also was data in the accreditation of international medical schools could be used for such as those in this The was for of the of IMGs and U.S. medical graduates and to undergraduate medical education, was that more should be to that increase the quality of In Dr. the for more including He also for of more evaluation, especially those the MD, Dr. is professor of and of in medicine, Texas College

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