Status of International Medical Graduates in Cardiology and Its Subspecialties in the United States

HomeCirculation: Cardiovascular Quality and OutcomesVol. 14, No. 11Status of International Medical Graduates in Cardiology and Its Subspecialties in the United States Free AccessLetterPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyRedditDiggEmail Jump toFree AccessLetterPDF/EPUBStatus of International Medical Graduates in Cardiology and Its Subspecialties in the United States Izza Shahid, MBBS, Muhammad Shahzeb Khan, MD, MSc, Safi U. Khan, MD, MS, Marat Fudim, MD, MHS, Garima Sharma, MD, Laxmi Mehta, MD and Khurram Nasir, MD Izza ShahidIzza Shahid https://orcid.org/0000-0003-3975-1197 Department of Medicine, Ziauddin Medical University, Karachi, Pakistan (I.S.). , Muhammad Shahzeb KhanMuhammad Shahzeb Khan https://orcid.org/0000-0003-1250-6351 Division of Cardiology, Duke University School of Medicine, Durham, NC (M.S.K., M.F.). , Safi U. KhanSafi U. Khan https://orcid.org/0000-0003-1559-6911 Division of Cardiovascular Prevention and Wellness, Department of Cardiology, Houston Methodist Debakey Heart and Vascular Institute, TX (S.U.K., K.N.). , Marat FudimMarat Fudim https://orcid.org/0000-0002-8671-7007 Division of Cardiology, Duke University School of Medicine, Durham, NC (M.S.K., M.F.). Duke Clinical Research Institute, Durham, NC (M.F.). , Garima SharmaGarima Sharma https://orcid.org/0000-0001-7254-2077 Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, MD (G.S.). , Laxmi MehtaLaxmi Mehta https://orcid.org/0000-0003-3493-1930 Division of Cardiology, Ohio State University Hospital, Columbus (L.M.). and Khurram NasirKhurram Nasir Correspondence to: Khurram Nasir, MD, Houston Methodist, Debakey Heart and Vascular Institute, Houston, TX. Email E-mail Address: [email protected] https://orcid.org/0000-0001-5376-2269 Division of Cardiovascular Prevention and Wellness, Department of Cardiology, Houston Methodist Debakey Heart and Vascular Institute, TX (S.U.K., K.N.). Originally published16 Nov 2021https://doi.org/10.1161/CIRCOUTCOMES.121.008196Circulation: Cardiovascular Quality and Outcomes. 2021;14:e008196International medical graduates (IMGs) constitute approximately one-quarter of the US physician workforce. The Association of American Medical Colleges report predicts a shortage of 54 100 to 139 000 physicians by 2033.1 Currently, these shortfalls are supplemented by including IMGs, who have historically filled gaps by working in geographic regions where US and Canadian medical graduates (USCGs) traditionally have not chosen to practice.2 However, political and health care policies, including restriction of travel and immigration regulations, can deter IMGs from seeking training in the United States.2 This may compound to the shortage of physician workforce, which can have adverse effects especially in specialties such as cardiology where an increase in workforce is of paramount importance given the growing burden of disease. In this study, we sought to examine the current representation of IMG trainees in cardiology and its subspecialties and compared it with data from the previous decade along with other specialties to identify pertinent trends.MethodsThe data that support the findings of this study are available from the corresponding author upon reasonable request. Data from the Association of American Medical Colleges were used to examine the representation of current (2019–2020) IMG and USCG trainees among training programs for general cardiovascular disease and 4 adult cardiology subspecialties recognized by the American Board of Internal Medicine, as well as pediatric cardiology.3 Since publicly available data were used, institutional review board approval was not required. The proportion of IMG trainees within adult cardiology and subspecialties for the year 2019-2020 were compared with the previous decade (2009–2020) and with other main Accreditation Council for Graduate Medical Education internal medicine specialties and non–internal medicine specialties.4 Trends over time (2009–2020) of IMG trainees in cardiology subspecialities were assessed using linear regression models. Additionally, we also analyzed results stratified by sex to explore sex imbalances within the active trainees, and χ2 tests were used to compare data. P<0.05 was considered significant.ResultsFor the training year 2019-2020, among all adult cardiology trainees, 39.2% (n=1451) were IMGs and 60.8% (n=2251) were USCGs. Among subspecialty training programs, interventional cardiology had the highest proportion of IMGs (53.0%; n=176), followed by cardiac electrophysiology (43.4%; n=102) and advanced heart failure/transplantation (37.4%; n=34). Conversely, adult congenital heart disease had the least percentage of IMGs (17.4%; n=4; Figure [A]). Over the past decade, a modest increase in the percentage of IMG training in adult cardiology was observed (2009–2010, 35.5% versus 2019–2020, 39.2%; P=0.13), which was predominantly driven by cardiac electrophysiology (P=0.03). In contrast, the percentage of IMG trainees in pediatric cardiology and adult congenital heart disease decreased significantly from the year 2009 to 2020 (Figure [B]). For other cardiology subspecialties, there was no significant change in the percentage of IMGs. IMG status of cardiology trainees was associated with greater sex disparity compared with USCGs. For both adult and pediatric cardiology, women IMGs made up 20.4% trainees (n=315) compared with the 29.9% USCGs (n=777; P<0.01) in the year 2019-2020. Compared with other internal medicine subspecialties, hematology (19.1%), gastroenterology (31.1%), rheumatology (33.4%), pulmonary and critical care medicine (38.8%), and cardiology (39.2%) were the 5 fields with the least IMG trainees (Figure [C]). Compared with non–internal medicine specialties, all specialties except pathology (anatomic and clinical; 47.9%) had lower proportion of IMG trainees than cardiology (39.2%). Orthopedic surgery had the least proportion (1.4%) of IMG trainees (Figure [D]).Download figureDownload PowerPointFigure. Depiction of the international medical graduate (IMG) trainees across the United States.A, Comparison of percentage of IMGs across different cardiology specialties and subspecialties (internal medicine [IM] shown for comparison) by decade. B, Trends of IMG trainees in cardiology subspecialties (IM shown for comparison) over the past decade (2009–2020) C, Percentage of active trainees by medical school for IM subspecialties for years 2019-2020. D, Percentage of active trainees by medical school for other specialties for the years 2019-2020. ˚Data available since 2012. †Data available since 2015. ACGME indicates Accreditation Council for Graduate Medical Education; HF, heart failure; and USCG, US and Canadian medical graduates.DiscussionOur results highlight that every 1 in 3 cardiology trainees is an IMG, with interventional cardiology representing the highest proportion of IMGs. This suggests that IMGs play a pivotal role in delivery of cardiology services in the United States, and a decrease in inflow of these international physicians may negatively affect access to health care in IMG dominant areas and specialties. Our analysis observed a modest albeit nonsignificant increase in the number of IMGs in adult cardiology over the past decade. The relatively large proportion of IMGs in cardiology may, in part, be driven by greater desire of IMGs to receive higher quality training, which may not be available in their own country.It is important to emphasize that majority of IMGs who are not US citizens face pervasive challenges while applying for training. These include but are not limited to the exorbitant fees required to receive Education Commission for Foreign Medical Graduates certification, the rigorous competition for residency, state rules governing medical licensing, and the uncertainty regarding securing a residency spot even after exhausting all resources, given that foreign training might not be considered at par when compared with in-house US graduates competing for the same position.To facilitate these IMGs, residency and fellowship training programs should encourage an environment of inclusivity. By both opening a dialogue on the issue and working with their local governments to advocate for IMGs, cardiovascular institutions and employers can create the change their international graduates need to succeed at their professions.5While there has been a lot of recent momentum to propagate principles of diversity, equity, and inclusivity in cardiology, recognition of the pervasive challenges faced by IMGs requires immediate attention. Further research is required to examine the proportion of IMG cardiologists who remain in the United States for practice and how the practice opportunities in underserved regions might be enhanced to attract more USCGs as well. Furthermore, if we are to remain a nation that continues to recruit international talent, we need to work together to find ways to retain them in our workforce.Article InformationSources of FundingNone.DisclosuresNone.FootnotesFor Sources of Funding and Disclosures, see page 1210.Correspondence to: Khurram Nasir, MD, Houston Methodist, Debakey Heart and Vascular Institute, Houston, TX. Email [email protected]orgReferences1. AAMC Press Release. New AAMC Report Confirms Growing Physician Shortage | AAMC n.d.Accessed April 29, 2021. https://www.aamc.org/news-insights/press-releases/new-aamc-report-confirms-growing-physician-shortage.Google Scholar2. Khullar D, Blumenthal DM, Olenski AR, Jena AB. U.S. immigration policy and American medical research: the scientific contributions of foreign medical graduates.Ann Intern Med. 2017; 167:584–586. doi: 10.7326/M17-1304CrossrefMedlineGoogle Scholar3. AAMC. Report on Residents: Table B3. Number of Active Residents, by Type of Medical School, GME Specialty, and Sex | AAMC n.d.Accessed April 29, 2021. https://www.aamc.org/data-reports/students-residents/interactive-data/report-residents/2020/table-b3-number-active-residents-type-medical-school-gme-specialty-and-sex.Google Scholar4. ACGME Data Resource Book n.d.Accessed April 29, 2021. https://www.acgme.org/About-Us/Publications-and-Resources/Graduate-Medical-Education-Data-Resource-Book.Google Scholar5. Chen PG, Auerbach DI, Muench U, Curry LA, Bradley EH. Policy solutions to address the foreign-educated and foreign-born health care workforce in the United States.Health Aff (Millwood). 2013; 32:1906–1913. doi: 10.1377/hlthaff.2013.0576CrossrefMedlineGoogle Scholar Previous Back to top Next FiguresReferencesRelatedDetails November 2021Vol 14, Issue 11Article InformationMetrics Download: 93 © 2021 American Heart Association, Inc.https://doi.org/10.1161/CIRCOUTCOMES.121.008196PMID: 34784230 Originally publishedNovember 16, 2021 Keywordshealth policyeducationfellowships and scholarshipsworkforceforeign medical graduatesPDF download Advertisement SubjectsDisparitiesEthics and PolicyHealth EquityHealth ServicesQuality and Outcomes

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