Do International Medical Graduates (IMGs) “Fill the Gap” in Rural Primary Care in the United States? A National Study

ABSTRACT:  Context: The contribution that international medical graduates (IMGs) make to reducing the rural-urban maldistribution of physicians in the United States is unclear. Quantifying the extent of such "gap filling" has significant implications for planning IMG workforce needs as well as other state and federal initiatives to increase the numbers of rural providers. Purpose: To compare the practice location of IMGs and US medical graduates (USMGs) practicing in primary care specialties. Methods: We used the 2002 AMA physician file to determine the practice location of all 205,063 primary care physicians in the United States. Practice locations were linked to the Rural-Urban Commuting Areas, and aggregated into urban, large rural, small rural, and isolated small rural areas. We determined the difference between the percentage of IMGs and percentage of USMGs in each type of geographic area. This was repeated for each Census Division and state. Findings: One quarter (24.8% or 50,804) of primary care physicians in the United States are IMGs. IMGs are significantly more likely to be female (31.9% vs 29.9%, P < .0001), older (mean ages 49.7 and 47.1 year, P < .0001), and less likely to practice family medicine (19.0% vs 38%, P < .0001) than USMGs. We found only two Census Divisions in which IMGs were relatively more likely than USMGs to practice in rural areas (East South Central and West North Central). However, we found 18 states in which IMGs were more likely, and 16 in which they were less likely to practice in rural areas than USMGs. Conclusions: IMGs fill gaps in the primary care workforce in many rural areas, but this varies widely between states. Policies aimed to redress the rural-urban physician maldistribution in the United States should take into account the vital role of IMGs .     

International medical graduates and the primary care workforce for rural underserved areas

The proportion of international medical graduates (IMGs) serving as primary care physicians in rural underserved areas (RUAs) has important policy implications. We analyzed the 2000 American Medical Association Masterfile and Area Resource File to calculate the percentage of primary care IMGs, relative to U.S. medical graduates (USMGs), working in RUAs. We found that 2.1 percent of both primary care USMGs and IMGs were in RUAs, where USMGs were more likely to be family physicians but less likely to be internists or pediatricians. IMGs appear to have been no more likely than USMGs were to practice primary care in RUAs, but the distribution by specialty differs.     

Are There Need-based Geographical Differences Between International Medical Graduates and U.S. Medical Graduates in Rural U.S. Counties?

The objectives of this study are to compare the rural location of international medical graduates (IMGs) and U.S. medical graduates (USMGs) by specialty (primary care vs. specialty care) according to geographical measures of need. This study utilized a cross-sectional survey using the 1997 American Medical Association Physician Masterfile for all active post-resident allopathic physicians and the Area Resource File (ARF) (Bureau of Health Professions, 1996) for all active post-resident osteopathic physicians in 1995 in the rural U.S. physician work force (N = 69,065). Allopathic physician ZIP code location was matched to county data using the ARF. The key measure was the difference in proportions between USMGs and IMGs in each state's rural counties characterized by need: high infant mortality, low socioeconomic status, high proportion of nonwhite population, high proportion of population 65 years and older, and low physician-to-population ratio. Primary care and specialty care rural physicians were studied separately. A disproportion of IMGs were located in needy rural counties of more states than were USMGs. Further, IMG disproportions were generally larger than USMG disproportions when they existed. Disproportions of IMGs tended to be located more often in the central and south census regions. Disproportions of specialty care IMGs were more frequent and of greater magnitude than those of primary care IMGs. Variations in the relative and absolute numbers of IMGs and USMGs among the states was wide. Services delivered by active post-resident primary care and specialty care IMGs appeared to be disproportionate to their overall number compared with USMGs in numerous needy rural counties. The extent of the IMG "safety net" presence differed, however, by the criteria used. Still, proposed limits on IMG entry into U.S. residency training may create long-term problems of access to rural physician services absent policies to induce USMGs or midlevel practitioners to locate in such areas. State-by-state assessments of the potential impact of IMG restrictions are called for because of the wide state-level variation that existed in comparative IMG-USMG distributions.     

Use of deceptive tactics in physician practices: are there differences between international and US medical graduates?

Concerns have been raised about the medical practices of international medical graduates (IMGs) in the United States. This study examined the differences between IMGs and US-trained medical graduates (USMGs) in their attitude toward and utilization of deception in medical practices. A random sample of physicians practicing in the US was surveyed by mail in 1998. The dependent variables of interest included 11 attitudinal and behavioral indicators of deceptive tactics in medical practice. IMGs and USMGs displayed limited difference 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, 0.557; 95% CI, 0.344-0.902) or to withhold a useful service because of utilization rules (OR, 0.612; 95% CI, 0.382-0.979). The hypothesis that IMGs have less appropriate professional standards than USMGs is not supported by this study. Alternative hypotheses, such as IMG familiarity with US health care and legal systems, warrant investigation.     

International medical graduate physicians in the United States: changes since 1981

Nearly a quarter of all active U.S. physicians are international medical graduates (IMGs)--physicians trained outside the United States and Canada. We describe changes in characteristics of IMGs from 1981 to 2001 and compare them with their U.S. medical graduate (USMG) counterparts. Since 1981, the leading source countries for IMGs have included India, the Philippines, and Mexico. IMGs were more likely to be generalists and to practice in designated underserved areas than USMGs but slightly less likely to practice in isolated small rural areas and persistent-poverty counties. IMGs are an important source of primary care physicians in rural and underserved areas.     

A methodology for assessing the professional development needs of nurses and midwives in Indonesia: paper 1 of 3

Background

The number of international medical graduates (IMGs) entering family medicine in the United States of America has steadily increased since 1997. Previous research has examined practice locations of these IMGs and their role in providing care to underserved populations. To our knowledge, research does not exist comparing professional profiles, credentials and attitudes among IMG and United States medical graduate (USMG) family physicians in the United States. The objective of this study is to determine, at the time when a large influx of IMGs into family medicine began, whether differences existed between USMG and IMG family physicians in regard to personal and professional characteristics and attitudes that may have implications for the health care system resulting from the increasing numbers of IMGs in family medicine in the United States.

Methods

This is a secondary data analysis of the 1996–1997 Community Tracking Study (CTS) Physician Survey comparing 2360 United States medical graduates and 366 international medical graduates who were nonfederal allopathic or osteopathic family physicians providing direct patient care for at least 20 hours per week.

Results

Compared to USMGs, IMGs were older (p < 0.001) and practised in smaller (p = 0.0072) and younger practices (p < 0.001). Significantly more IMGs practised in metropolitan areas versus rural areas (p = 0.0454). More IMG practices were open to all new Medicaid (p = 0.018) and Medicare (p = 0.0451) patients, and a greater percentage of their revenue was derived from these patients (p = 0.0020 and p = 0.0310). Fewer IMGs were board-certified (p < 0.001). More IMGs were dissatisfied with their overall careers (p = 0.0190). IMGs and USMGs did not differ in terms of self-rated ability to deliver high-quality care to their patients (p = 0.4626). For several of the clinical vignettes, IMGs were more likely to order tests, refer patients to specialists or require office visits than USMGs.

Conclusion

There are significant differences between IMG and USMG family physicians' professional profiles and attitudes. These differences from 1997 merit further exploration and possible follow-up, given the increased proportion of family physicians who are IMGs in the United States.     

Variations in geographical distribution of foreign and domestically trained physicians in the United States: 'safety nets' or 'surplus exacerbation'?

In the United States, a debate has existed for decades about whether foreign-trained physicians (known in the US as 'international medical graduates' or 'IMGs') and US medical graduates (USMGs) have been differentially distributed such that IMGs were more likely to be found in locales characterized as high in need or medical underservice. This 'safety net' hypothesis has been countered by the IMG 'surplus exacerbation' argument that IMGs have simply swelled an already abundant supply of physicians without any disproportionate service to areas in need. Through an analysis of the American Medical Association Physician Masterfile and the Area Resource File, we classified post-resident IMGs and USMGs into low and high need counties in each of the US states, compared the percentage distributions, and determined whether IMGs were found disproportionately in high need or underserved counties. Using four measures (infant mortality rate, socio-economic status, proportion non-white population, and rural county designation), we show 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 high 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 US physician 'surplus' and initiatives to reduce the number of IMGs in residency training.     

The contribution of international medical graduates to diversity in the U.S. physician workforce: graduate medical education

PURPOSE: To describe the ethnicity/race and gender distribution of the international medical graduates (IMGs) qualified to enter graduate medical education (GME) and those who are actually in GME. METHODS: The Educational Commission for Foreign Medical Graduates (ECFMG) database and the American Medical Association's Masterfile provided ethnicity/race and gender data for the pool of IMGs qualified to enter GME (ECFMG certificants from 2000-2005) and those in GME in 2005. Data for U.S. medical graduates come from Association of American Medical Colleges' publications. RESULTS: Compared with USMGs, both the pool of available IMGs and those in graduate training have a larger percentage of Asians and Hispanics, a lower percentage of Blacks and American Indian/Pacific Islanders, and a much lower percentage of Whites. The groups had comparable percentages of women. CONCLUSIONS: International medical graduates provide much-needed diversity in GME. Since most IMGs remain in the U.S. after training, this diversity can lead to a richer training environment, increased access to health care, and better health care outcomes.     

The use of standardised patients to assess clinical competence: does practice make perfect?

CONTEXT: The use of standardised patients (SPs) is now an integral component of the United States Medical Licensing Examination (USMLE). This new requirement has caused more schools to include SP examinations (SPEs) in their curricula. This study reviews the effect of prior experience with SPs in a medical school curriculum on SPE pass rates. METHODS: This study reviewed the mean scores and pass rates on a 4-station SPE, comparing the performance of 121 US medical school graduates (USMGs) with that of 228 international medical graduates (IMGs). The analysis of USMGs' performance was based upon whether the resident had had previous exposure to an SPE during medical school, while the analysis of IMGs' performance was based upon whether the IMG had taken the Clinical Skills Assessment (CSA) for certification by the Education Commission for Foreign Medical Graduates. A distinction was made between those who had received prior exposure at Mount Sinai School of Medicine's Morchand Center, where the cases utilised were identical to those of the SPE, and those who had gained exposure elsewhere. RESULTS: Neither the mean scores of the IMGs and the USMGs nor the percentage who failed was significantly different relative to prior exposure to SPs. CONCLUSION: Prior exposure to SPs does not appear to have a positive effect on subsequent performance on an SPE unless similar or identical cases are used. However, the type and site of prior exposure limited the influence of the review. In view of the increased use of SPEs in medical schools, the content of prior exposure needs to be more fully established.     

Initial practice locations of international medical graduates

OBJECTIVE: To examine the influence of place of graduate medical education (GME), state licensure requirements, presence of established international medical graduates (IMGs), and ethnic communities on the initial practice location choices of new IMGs. DATA SOURCES: The annual Graduate Medical Education (GME) Survey of the American Medical Association (AMA) and the AMA Physician Masterfile. STUDY DESIGN: We identified 19,940 IMGs who completed GME in the United States between 1989 and 1994 and who were in patient care practice 4.5 years later. We used conditional logit regression analysis to assess the effect of market area characteristics on the choice of practice location. The key explanatory variables in the regression models were whether the market area was in the state of GME, the years of GME required for state licensure, the proportion of IMGs among established physicians, and the ethnic composition of the market area. PRINCIPAL FINDINGS: The IMGs tended to locate in the same state as their GME training. Foreign-born IMGs were less likely to locate in markets with more stringent licensure requirements, and were more likely to locate in markets with higher proportions of established IMG physicians. The IMGs born in Hispanic or Asian countries were more likely to locate in markets with higher proportions of the corresponding ethnic group. CONCLUSIONS: Policymakers may influence the flow of new IMGs into states by changing the availability of GME positions. IMGs tend to favor the same markets over time, suggesting that networks among established IMGs play a role in attracting new IMGs. Further, IMGs choose their practice locations based on ethnic matching.     

Practising medicine in two countries: South African physicians in Canada

This qualitative study examines the pre‐ and post‐migration practice experiences of 73 physicians trained in South Africa who have relocated to Canada. The aims are to explore the workings of two different healthcare systems from an insider standpoint and to address the medical autonomy debate as it relates to international medical graduates (IMGs). While study respondents reported practice frustrations in both countries, they generally preferred working in a socialised health insurance environment that grants wider accessibility than a two‐tiered system that favours a privileged few. Concerns such as family safety and opportunities for children also contributed to more satisfaction with Canada. We discuss our findings in relation to a broader international context and the sociological literature on medical autonomy. We argue that IMGs face different autonomy issues from other physicians and stress the need to broaden sociological inquiry of medical work by investigating how autonomy interfaces with other neglected aspects of physicians’ work and non‐work lives.     

A Comparison of Metropolitan and Rural Medical Schools in China: Which Schools Provide Rural Physicians?

ABSTRACT: To compare the role of metropolitan and rural medical schools in the provision of rural physicians, a survey was conducted in 12 metropolitan and 10 rural medical schools. Rural medical schools enrolled fewer students (P = 0.019), and produced fewer graduates (P = 0.023) than metropolitan medical schools. Students in rural medical schools were mainly from surrounding regional cities and counties, whereas those in metropolitan schools were from cities nationwide (P < 0.001). All rural medical schools produced rural physicians; one rural school reported that of its 256 graduates, 88 (34.4%) entered rural practice. Ten of the 12 metropolitan medical schools did not produce any rural physicians, whereas the remaining two metropolitan schools registered a total of 73 graduates who selected a rural practice location. These results indicate that rural medical schools may play a key role in overcoming the shortage of physicians in rural communities in China.     

International Medical Graduates in Rural America: The 1987 Distribution of Physicians Who Entered the U.S. Medical System Between 1969 and 1982

This study examines the differential location on Dec. 31, 1987, in nonmetropolitan U.S. counties of a cohort of international medical graduates (IMGs) (n = 246,754) certified by the Educational Commission for Foreign Medical Graduates between 1969 and 1982, and a matched group of U.S. medical graduates (USMGs). Analysis of counties grouped into categories of population size revealed disparities across certain U.S. census divisions. IMGs were distributed disproportionately in the West North Central and East South Central census divisions. The implications of the IMG presence in numerous rural counties is discussed from the perspective of recent policy proposals to reduce the number of IMGs in the United States.     

The primary care physician workforce: ethical and policy implications

PURPOSE We undertook a study to examine the characteristics of countries exporting physicians to the United States according to their relative contribution to the primary care supply in the United States.METHODS We used data from the World Health Organization and from the American Medical Association Physician Masterfile to gather sociodemographic, health system, and health characteristics of countries and the number of international medical graduates (IMGs) for the countries, according to the specialty of their practice in the United States.RESULTS Countries whose medical school graduates added a relatively greater percentage of the primary care physicians than the overall percentage of primary care physicians in the United States (31%) were poor countries with relatively extreme physician shortages, high infant mortality rates, lower life expectancies, and lower immunization rates than countries contributing relatively more specialists to the US physician workforce.CONCLUSION The United States disproportionately uses graduates of foreign medical schools from the poorest and most deprived countries to maintain its primary care physician supply. The ethical aspects of depending on foreign medical graduates is an important issue, especially when it deprives disadvantaged countries of their graduates to buttress a declining US primary care physician supply.     

The international medical graduate pipeline: recent trends in certification and residency training

International medical graduates (IMGs) represent a large proportion of the population entering graduate medical education (GME) programs. Many of these internationally trained physicians go on to practice medicine in the United States. To be eligible for GME, IMGs must be certified by the Educational Commission for Foreign Medical Graduates (ECFMG). The number of certificates issued by the ECFMG has varied over time and historically has exceeded the number of available training positions. More detailed longitudinal analyses are required to better understand the interwoven issues of physician supply, consumers' needs, and the role of IMGs in the U.S. health care system.     

International and US medical graduates in US cities

Objectives This study examines the comparative distributions of postresident international medical graduates (IMGs) and US medical graduates (USMGs) in high and low poverty areas of US cities. Existing research has established that IMGs are more likely than USMGs to practice in urban areas, yet there is the question whether IMGs locate more frequently than USMGs in urban poverty areas. Methods Data from the 1997 AMA Physician Masterfile and 1990 US Census were merged to classify physicians' practices into low- and high-poverty areas in selected cities. Results In 14 cities with populations of 2.5 million or more, IMGs were located in a statistically significant disproportion in poverty areas of 7 cities. Of 36 cities with populations of 1,000,000 to 2,499,999, there were 5 cities that had significant IMG disproportions in poverty areas. Of a random sample of 27 cities with populations of 250,000 to 999,999, there were 2 cities that had significant IMG disproportions. Many cities in all three size categories had a large proportionate IMG complement of the total physician workforce located within high-poverty areas. Conclusions IMGs were found in disproportionate numbers in poverty areas in a number of US cities, especially the very largest ones. These findings are discussed in light of the current debate about a physician surplus and initiatives to reduce the number of IMGs in residency training.     

海军医学毕业生胜任特征模型的构建

目的建立海军医学毕业生胜任力特征模型。方法采用调查法和专家小组讨论确立海医医学毕业生胜任特征要素,运用探索性因素分析（EFA）构建海军医学毕业生胜任特征模型。结果建立包含使命导向、团队合作、沟通能力、问题解决能力、心理调适5个维度21个条目的海军医学毕业生胜任特征模型。结论本模型的5个维度表征了海军医学毕业生的胜任特征,战士生源毕业生对使命导向和沟通能力重要性评价显著高于地方生源毕业生。     

Attracting physicians to underserved communities: the role of health networks

As health networks battle for additional market share and encourage additional Medicaid HMO subscribers to use their physicians and hospitals, more health executives are analyzing proposals of how to attract qualified doctors to practice in poor rural or inner-city communities. Supplying more physicians to those areas by increasing the number of medical schools, expanding the National Health Service Corps (NHSC) program, and allowing more international medical graduates (IMGs) to pursue residency training in the United States have been relatively unsuccessful strategies to improve America's geographic maldistribution of medical manpower. This article focuses on several approaches that health networks might use to increase market penetration and at the same time deliver enhanced health services to the underserved. Health networks may provide eminent leadership in the overall design and governance of soundly conceived Medicaid HMOs; strengthen existing or develop additional community health/primary care centers; interface more effectively with local schools to foster Medicaid HMOs for children of low-income families; and reimburse at "premium rates" primary care physicians who practice in underserved communities. The reluctance of physicians to practice in these areas and of middle-income and upper-income taxpayers, and therefore elected officials, to support increased spending or redirection of funds continue to be major barriers for health alliances to demonstrate willingness to invest additional resources in poor inner-city and rural environments.