imgs in american medicine - contemporary challenges and opportunities

8/2/2019 IMGs in American Medicine - Contemporary Challenges and Opportunities

1/45iInternational medical graduates in American medicine Contemporary challenges and opportunities | January 2010

InternatIonal medIcal graduates

In amerIcan medIcIne:Contemporary challenges and opportunities

A position paper by the AMA-IMG Section Governing Council

January 2010


2/45IInternational medical graduates in American medicine Contemporary challenges and opportunities | January 2010

Table o contents

Page

Acknowledgements .............................................................................................................................................................. 1

Foreword .............. ............... .............. ............... .............. ............... .............. ............... .............. ............... .............. ............... . 2

Introduction ............. .............. ............... .............. ............... .............. ............... .............. ............... .............. ............... ............. 3

Profle o IMGs ............... .............. ............... .............. ............... .............. ............... .............. ............... .............. ............... ...... 4

Historical context o medical education and migration.................................................................................................... 7

History o the ECFMG ............... ............... .............. ............... .............. ............... .............. ............... .............. ............... ...... 10

Controversies in physician work orce recommendations .............. ............... .............. ............... .............. ............... ...... 12

Council on Graduate Medical Education.............. ............... ................ ............... ................ ............... ............... ................ ............ 12

Pew Health Proessions Commission ............... ................ ............... ................ ............... ............... ................ ............... ............... 12

A consensus statement .............. ................ ............... ................ ............... ............... ................ ............... ................ ............... ....... 12

The Institute o Medicine ............... ............... ................ ............... ................ ............... ............... ................ ............... ................ .... 13

Managed care .............. ............... ................ ............... ................ ............... ............... ................ ............... ................ ............... ....... 13

Reduce GME unding ............... ............... ................ ............... ............... ................ ............... ................ ............... ............... .......... 13

Physician work orce recommendation implications .............. ............... ................ ............... ................ ............... ............... .......... 14

IMG contributions ............... .............. ............... .............. ............... .............. ............... .............. ............... .............. .............. 15

Gap flling or saety net role ............. ................ ............... ................ ............... ............... ................ ............... ................ ............... .. 15

IMGs in primary care ................ ............... ................ ............... ............... ................ ............... ................ ............... ............... .......... 17

IMGs in academic medicine and research .............. ............... ............... ................ ............... ................ ............... ............... .......... 19

2009 Nobel Prize scientists ............. ................ ............... ................ ............... ............... ................ ............... ................ ............... .. 20

Trends among IMG aculty at U.S. medical schools: 19812000..................... ............... ............... ................ ............... ............... 20

Immigration ............... ................ ............... ................ ............... ............... ................ ............... ................ ............... ............... .......... 20

Graduate medical education .............. .............. ............... .............. ............... .............. ............... .............. ............... ........... 22

Selecting residency programs ............... ............... ............... ................ ............... ................ ............... ............... ................ ............ 22ECFMG certifcation .............. ................ ............... ............... ................ ............... ................ ............... ............... ................ ............ 22

Applying to graduate medical education programs ............... ............... ................ ............... ................ ............... ............... .......... 22

National Resident Matching Program ............... ................ ............... ................ ............... ............... ................ ............... ............... 23

Obtaining a residency position in the United States .............. ............... ................ ............... ................ ............... ............... .......... 26

International medical schools ................ ............... ............... ................ ............... ................ ............... ............... ................ ............ 27

Observerships ............... ................ ............... ................ ............... ............... ................ ............... ................ ............... ................ .... 27

Immigration and visas ............... ............... .............. ............... .............. ............... .............. ............... .............. ............... ...... 29

Temporary worker H-1B visa .............. ............... ................ ............... ................ ............... ............... ................ ............... ............... 30

Immigrant visas ............. ................ ............... ................ ............... ............... ................ ............... ................ ............... ................ .... 30

Signifcant dates in U.S. immigration policy aecting IMGs ............... ............... ................ ............... ............... ................ ............ 30

USIMGs ............... ................ ............... ............... ................ ............... ................ ............... ............... ................ ............... ............... 31

Dynamics o migration: Brain drain ............... .............. ............... .............. ............... .............. ............... .............. .............. 33

Conclusion .............. .............. ............... .............. ............... .............. ............... .............. ............... .............. ............... ........... 35

Recommendations ............. .............. ............... .............. ............... .............. ............... .............. ............... .............. .............. 36


3/45IIInternational medical graduates in American medicine Contemporary challenges and opportunities | January 2010

Page

IMGs in organized medicine ............... .............. ............... .............. ............... .............. ............... .............. ............... ........... 37

20092010 AMA-IMG Section Governing Council .............. ................ ............... ................ ............... ............... ................ ............ 37

State medical societies with IMG sections..................... ................ ............... ............... ................ ............... ................ ............... .. 37

Reerences .............. .............. ............... .............. ............... .............. ............... .............. ............... .............. ............... ........... 38

Additional recommended resources ................................................................................................................................ 41

Appendix A: Index o tables and graphs .......................................................................................................................... 42

Table o contents (continued)


4/451International medical graduates in American medicine Contemporary challenges and opportunities | January 2010

Acknowledgements

Te American Medical Association (AMA) InternationalMedical Graduates (IMG) Section Governing Councilwould like to acknowledge the valuable contributions othe ollowing individuals, without their expertise andcommitment, this paper would not be possible.

Nyapati Raghu Rao, MD, chair o the AMA-IMG SectionWorkorce Paper Committee, Department o Psychiatry andBehavioral Sciences, Nassau University Medical Center, N.Y.

Rajam Ramamurthy, MD, AMA-IMG Section WorkorcePaper Committee member, neonatologist, San Antonio

Mitra Kalelkar, MD, AMA-IMG Section Workorce PaperCommittee member, deputy medical examiner,Cook County, Ill.

Jayesh Shah, MD, AMA-IMG Section Workorce PaperCommittee member, AMA-IMG Section Governing Councilchair, hyperbaric medicine, San Antonio

VijayaLakshmi Appareddy, MD, AMA-IMG Section Work-orce Paper Committee member, psychiatrist, president ori-State Psychiatric Services, Chattanooga, enn.

Raouf Seifeldin, MD, AMA-IMG Section Workorce PaperCommittee member, AMA-IMG Section Governing Councilvice-chair, amily medicine, Pontiac, Mich.

Padmini Ranasinghe, MD, AMA-IMG Section WorkorcePaper Committee member, AMA-IMG Section alternatedelegate to the AMA House o Delegates, internal medicine,Johns Hopkins, Baltimore

Jack Boulet, PhD, associate vice president, research anddata resources, Foundation or Advancement o InternationalMedical Education and Research, Philadelphia

Back to table o contents



International medical graduates (IMGs) have been an inte-gral part o American medicine since the late 1940s. Tesegraduates arrived in America rom more than 125 countrieswith varying cultural and linguistic backgrounds in searcho advanced knowledge and skills in medical institutions ohigher learning. In looking at the challenges they ace, the

sacrices they make, the disappointments they encounterand the successes they achieve, the IMG journey is otenarduous and heroic.

In the words o Jordan Cohen, MD, ormer president o theAssociation o American Medical Colleges, Indeed, examplesabound o IMGs who have improved health care delivery,provided care to underserved populations, made ground-breaking discoveries in biomedical research, introduce newsurgical techniques, pioneered innovative teaching methods,and more (Jordan, 2006). And he is correctthere aremultiple acets to the IMG story.

Among all advanced nations, America is the most welcomingcountry to IMGs. Nonetheless, the presence o IMGs inAmerica has raised questions about the soundness andadequacy o IMGs medical education, the quality o themedical care they deliver, their contribution to increasingthe physician supply and deepening the physician maldistri-bution and nally, causing brain drain. On the other hand,IMGs oten eel perplexed, overwhelmed and discriminatedagainst, although they also eel appreciative o theopportunity to receive world-class medical training.

o start, IMG presence in the United States is the latest

episode in medical migration, which is an age-oldphenomenon. From the Civil War to World War II, Americanswent abroad or advanced medical education and broughtback new knowledge and skills that improved the wayAmerican medicine was practiced and taught. Now Americahosts physicians rom all over the world seeking similaropportunities, even though a majority o these internationalgraduates do not return to their native lands atercompletion o their training.

Understandably there are considerable concerns over thebrain drain phenomenonthat is, depleting poor nationso their scarce physician resources. At the same time, someeel there is insucient appreciation o American values,quality control systems and American currency, all o whichhelp to improve the living conditions and the manner inwhich medicine is practiced and taught in oreign countries.Tis cultural and educational exchange is perhaps the mostbenecial, but intangible, aspect o IMG and U.S. interaction.Te value o this exchange is equal to the work done bythousands o U.S. Peace Corps volunteers in all corners o theworld without a single penny spent by taxpayers. In addition,

the entry o approximately 6,000 IMGs into the United Statesevery year contributes a ew billion dollars to the U.S.economy, which is equal to the output o 50 additionalmedical schools without any cost to the taxpayer.

It becomes evident that the story o IMGs is a very complex

one indeed, and in this document, the American MedicalAssociation (AMA) IMG Section committee will provide acomprehensive review o IMG literature. Te background othis document begins with Rajam Ramamurthy, MD, whoserved as chair to the AMA-IMG Governing Council rom2004 to 2005. During her tenure, the governing counciladdressed the issues related to IMGs role in the U.S. physicianwork orce by creating a document titled IMGs in Americanmedicine: A discussion paper. Tis paper was updated annu-ally by each years governing councils work orce committee.In view o dramatic changes taking place with the nationshealth care reorm and the expansion o U.S. medical schooloutput, the discussion paper was subjected to a thoroughrevision this year. Its title was also slightly changed and isnow International medical graduates in American medicine:Contemporary challenges and opportunities.

Tis paper begins with a description o the history o IMGs inthe United States in the context o the evolution o graduatemedical education. It reviews the controversies surroundingphysician supply, as well as IMGs role in health care delivery.It presents the current demographics in the IMG work orce,highlighting the resilience o IMGs. In addition, the paperdiscusses issues concerning brain drain and the IMGs rolein the organizational structure at the AMA. Te discussion

concludes with recommendations stemming rom the issuesdiscussed. opics were chosen to reect major priorities inthe proessional and educational lie o IMGs.

In spite o our best eforts, it is very dicult to comprehensivelyaddress all topics that pertain to IMGs in a single document.One may nd that some topics lack depth, while others mightrequire urther elucidation. As editor o this document, and aschair o the AMA-IMG Section Workorce Paper Committee,I ound the experience extremely stimulating and enriching.I thank members o the work orce committee or thegenerosity o their time and eforts, and AMA staf, led by

J. Mori Johnson and Carolyn Carter-Ellis, or their extraor-dinary support o this project. Tey gave me a ree hand inthe choices made, participated in multiple phone calls andsubmitted their contributions with great enthusiasm.

Nyapati R. Rao, MD, MS

Chair, AMA-IMG Section Workorce Paper CommitteeChairman, Department o Psychiatry and Behavioral ScienceChie academic ocer, Nassau University Medical Center

Foreword




Medical migration, the phenomenon o physicians travelingar and wide in search o new knowledge and skills, has beenpracticed or several centuries. China, Great Britain, France,Germany and now the United States have all attracted inter-national students at diferent times by their dominance omedical education and practice. In the 19th century, Ameri-

can physicians traveled to Europe, especially France andGermany, to pursue medical education. When they returned,the knowledge and skills these physicians brought back tothe United States prooundly changed medicine in America(Baron, 2005). Since the end o World War II, the UnitedStates has been the preerred destination or physicians romall over the world or training in graduate medicine. However,these recent international physician visitors difered romprevious generations in that they requently did not returnto their native countryinstead, these physicians made theUnited States their home.

Physicians who received their undergraduate medicaleducation outside o the United States and Canada arereerred to as international medical graduates (IMGs).IMGs are a heterogeneous group rom more than 127nations with varying cultural and linguistic backgrounds,and they are critical to delivering health care in the UnitedStates. In 1963, IMGs represented slightly more than 10percent o the physician work orce in the United States.oday, they comprise 25 percent o the U.S. physicianpopulation.

In the ollowing pages, the American Medical Association(AMA) IMG Section Workorce Paper Committee will

examine various aspects o the IMG presence in the U.S.physician work orce. Tere are several purposes or writingthis position paper. First, we want to tell the story o IMGs.We also seek to ofer our perspective on some o the issuesthat conront IMGs in order to place IMG presence in ahistorical context, to clariy misconceptions, to highlightIMG contributions, and to conront unair and biasedcriticism wherever it occurs.

Introduction




An examination o IMG demographics reveals that amajority o present-day IMGs are clinicians. According toJordan Cohen, MD, and Fitzhugh Mullan, MD, 25.8 percento total physicians are in patient care (Jordan, 2006) (Mullan,1995). Within the IMG physician population, 77.5 percentare in patient care. O these IMGs (188,638), nearly three-

quarters are oce-based physicians. In addition, one-tho all physicians are in research (19.6 percent), and 1 out o6 physicians who are in medical teaching (16.8 percent)were IMGs. Only 13.5 percent o all physicians are inadministration. wenty percent o all IMGs are inresearch and 13.5 percent are in administration.

Table 1

General IMG statistics, 2007

Number o physicians in U.S. 941,304

Number o IMG physicians 243,457 (rom 127 countries)

% I MG physicians in U.S. 26.0

% IMGs in residency programs 27.8

% IMGs in primary care 58.0

% U SMGs in primary care 26.0

% IMGs in patient care 73.0

% IMGs in academics 14.0

Percentages exclude resident/ellows unless otherwise statedPhysician Characteristics and Distribution in the U.S., American Medical Association, 2009

IMGs are chiey concentrated in New York, Caliornia,Florida, New Jersey and Illinois. Te top ve countries oorigin among IMGs are India, Te Philippines, Mexico,Pakistan and the Dominican Republic.

Table 2

Top 20 countries o medical education or IMG physicians% o total IMG population (number o physicians)

cy t P

India 51,447 20.7%

Philippines 20,601 8.3%

Mexico 13,834 5.6%

Pakistan 12,111 4.9%

Dominican Republic 7,979 3.2%

Grenada 6,749 2.7%

USSR 6,450 2.6%

Dominica 5,854 2.4%

China 5,375 2.2%

Egypt 5,266 2.1%

Iran 4,940 2.0%

South Korea 4,845 2.0%

Italy 4,732 1.9%

Spain 4,343 1.8%

Germany 4,197 1.7%

Syria 3,869 1.6%

United Kingdom 3,698 1.5%

Montserrat 3,569 1.4%

Colombia 3,343 1.3%

Ireland 3,302 1.3%

American Medical Association Physician Masterfle, 2009

Table 3

Top 20 states where IMGs practice, 2007

s t b f ImgP f phyii wk f

1. New York 35,934 42%

2. Caliornia 26,209 23%

3. Florida 20,243 37%

4. New Jersey 13,824 45%5. Texas 13,705 24%

6. Illinois 13,698 34%

7. Pennsylvania 11,231 26%

8. Ohio 10,046 29%

9. Michigan 9,749 34%

10. Maryland 7,262 27%

11. Massachusetts 7,377 22%

12. Virginia 5,197 22%

13. Georgia 4,597 20%

14. Connectcut 4,339 29%

15. Missouri 3,600 22%

16. Arizona 3,461 22%

17. North Carolina 3,393 13%

18. Indiana 3,238 21%

19. Tennessee 3,069 17%

20. Wisconsin 3,075 19%

Physician Characteristics and Distribution in the U.S., American Medical Association, 2009

Table 4

Primary specialty o IMGs, percentage in specialty

(number o IMG physicians)

Internal medicine 37% (58,818)

Anesthesiology 28% (11,717)

Psychiatry 32% (13,146)

Pediatrics 28% (20,647)

Family medicine 27% (23,111)

Obstetrics/gynecology 17% (7,465)

Radiology 19% (1,681)

General surgery 20% (7,353)


Profle o IMGs




Table 5

IMGs by age and major proessional activity, 2007

5564

19.8%

Over 65

21.8%

Under 35

13.2%

3544

23.3%

Hospital-based

23.3%Patient care

80.1%

Ofce-based

57.9%

All other

categories

21.8%

4554

22.0%


Table 6

IMGs by gender and sel-designated specialty, 2007*

0 5,000 10,000 15,000 20,000 25,000 30,000 35,000 40,000 45,000

Anesthesiology

Family Medicine

General Practice

General Surgery

Internal Medicine

Obstetrics/Gyn.

Pathology-Anatomy/Clin.

Pediatrics

Psychiatry

Male

Female



IMGs by age IMGs by activity

Nearly twice as many IMGs were in the 35 to 44 age group in2007 than in the under-35 age group. Female IMGs constituted30.6 percent o the IMG complement. In other words, 87 per-cent o IMGs are 35 years and older and, in this aspect, aremore similar in age to a second-career physician among U.S.medical graduates (USMGs). Te implications o this act areimportant. For example, a more mature IMG, while carryingout his patient care activity with a greater sense o responsi-bility than his younger colleague, may exert a stabilizing

inuence on younger colleagues who are in residencytraining. On the other hand, the graying o the IMG populationmay presage their ultimate extinction rom the physicianwork orce, which could have signicant public healthramications.

Nearly three-ths o IMGs are in the ollowing specialties:internal medicine, pediatrics, amily medicine, psychiatry,anesthesiology, obstetrics-gynecology, general surgeryand cardiology.



Table 7

Percentages o IMGs in highest IMG sel-designated

specialties, ranked by size, 2007

t Img (%) rk

spiy 1980 2007 1980 2007

Internal medicine 13.4% 24.2% 1 1

General/Family medicine 9.4% 9.5% 2 2

Pediatrics 6.8% 8.5% 5 3

Psychiatry 7.0% 5.4% 3 4

Anesthesiology 6.0% 4.8% 6 5

Obstetrics/gynecology 5.4% 3.1% 7 6

General surgery 6.9% 3.0% 4 7

Cardiovascular disease 2.3% 2.8% 9 8

Pathology 4.0% 2.6% 8 9


Te presence o IMGs has been controversial on many levels.Questions have been raised about the quality o care IMGsdeliver and their contributions to physician maldistribution

and physician surplus. Approximately 75 percent o all physi-cians who train in the United States ultimately establish theirpractices here and, in this regard, they difer rom physiciansin earlier generations (Mullan, 1995). Some believe that thistendency o IMGs to permanently reside in the United Statescontributes to a physician surplus, and consequently, havecalled or limiting IMGs entry into graduate medical edu-cation (GME) and eventually to lower the number o IMGsamong practicing physicians (Education & Report, 1998).

Additionally, some doubt the quality o IMGs medicaleducation and their capacity to unction as physicians in the

United States (orrey, 1973). Others believe that IMGs, byseeking training in certain specialties, worsen the problemo physician maldistribution in the United States (Mullan,1995). Finally, there is the issue o brain drainimpoverishednations losing their precious, educated human talent to theWest. Tis is a topic that has been extensively commentedupon in the recent proessional literature (Mullan, 2005).

Other researchers counter these arguments by stating thatIMGs perorm a unique saety-net unction by caring or theuninsured and the indigent populations in inner city andrural areas, in contrast to U.S. medical graduates (USMGs)(Mick, 2000) (Baers, 1998). Similarly, Mick contends that theallegation o inerior perormance by IMGs is questionable(Mick, 1997).




Te history o IMGs in the United States is closelyintertwined with the evolution o the countrys medicaleducation, and in the ollowing pages, the major themes inGME will be discussed to provide an understanding o IMGsentry and continued presence in the U.S. physician workorce. Tis historical context is critical to appreciating and

understanding the issues aced by IMGs today. GME inthe United States evolved rom being a loosely structuredexperience to a highly regulated and closely monitoredsystem o graduate education o physicians, where even thenumber o hours they sleep is under scrutiny. IMGs leavebehind their own disparate systems and must conront thisorderly clinical teaching enterprise o GME, which is vastlydiferent rom their own. (Te review o the history o GMEis obtained primarily rom Kenneth Ludmerers landmarkpublications,Learning o Healand ime to Heal.)

In mid-19th century, America was ravaged by inectiousdiseases, and medications were not available, with theexception o chloroorm and ether or anesthesia, andquinine to treat malaria. Amputation was the standardtreatment or injured limbs, and the poor quality o surgeryis reected in an 87 percent mortality rate o all amputationsconducted during the Civil War. In contrast, there was onlya 3 percent mortality rate or this procedure in World War II.Elementary techniques o the physical exam, such as measur-ing temperature, percussing the chest or using stethoscopesor ophthalmoscopes were done by very ew physicians. In1800, only three medical schools existed: the University oPennsylvania, Harvard Medical School, and Kings College(now Columbia University). Instruction at medical schoolsconsisted o two our-month terms o lectures during thewinter season, with the second term identical to the rst.Tere were no entrance requirements, nor were there anyexaminations or grades. Diplomas could be bought, so muchso it was stated that an American physician or surgeon maybe, and oten is, a coarse and uncultured person, devoid ointellectual interests outside o his calling, and quite unableto either speak or write his mother tongue with accuracy(Ludmerer, 1996).

Against this backdrop, American physicians exposure to twooreign medical systems, Germany and France, was critical

in liting American medicine out o the morass it was inand setting it on the path to excellence. In the early 1800s,France was the avorite destination or American physicianswho were eager to work alongside such luminaries as LouisPasteur, Claude Barnard and Xavier Bichat. Te phrasepeulire, beaucoup voir, beaucoup aire, read little, see much, domuch, embodied the principle o education in France (Baron,2005). French medicine emphasized the importance o keenobservation o clinical phenomena and letting acts speak orthemselves and eschewed grand theories. It also pioneeredthe study o the natural history o disease and o therapeuticsby the use o numerical or statistical methods. Tese inu-

ences o French medicine acted as an antidote to outlandishtheories and speculative abuses that existed in Americanmedicine. American physicians were greatly inuenced bythe French methods in that they practiced observation anddistrusted experimental research and laboratory medicine.

By the middle o the 19th century, however, French medicine,due to its lack o research basis and its disdain or biologicalsciences, caused its own downall rom its preeminent posi-tion and consequently lost its allure or American students.Instead, Americans turned to Germany, which had becomethe center o European medicine. Tey were attracted byLehrreiheit, or reedom o teaching, andLernreiheit,reedom o learningthe twin principles o German educa-tion. In addition, some o the eatures o German education,such as ull-time salaried proessors, division o educationinto undergraduate and postgraduate domains, creation ospecialties and subspecialties, and an emphasis on laboratoryscience (all too common in the U.S. now, but novelties at thetime) also attracted Americans. All these developments setthe stage or the evolution o academic medicine aroundthe activities o the medical school located in the university.Tese students returned to the United States to practice theirnew skills and, in this regard, were diferent rom the IMGphysicians o the 21st century, who come to the United Statesand generally stay here.

Despite these positive developments, there were stillmany problems with the system due to lack o uniormstandards and requirements. Medical education was alucrative business due to prolieration o proprietary schools,

but several issues still needed to be resolved: a need oruniorm standards, the enorcement o uniorm admissioncriteria, establishing the importance o research, andcreating an aliation with a university or all medicalschools. Ludmerer, writing in 1985, describes medicaleducation in the United States, saying, A century ago,being a medical student in America was easy. No one worriedabout admission, or entrance requirements were lower thanthey were or a good high school. Instruction was supercialand brie. Te terms only lasted or 18 weeks, and ater thesecond term, the MD degree was automatically given,regardless o a students academic perormance. eaching

was by lecture alone, thus, students were spared theonerous chores o attending laboratories, clinics, andhospital wards students would oten graduate withoutever having touched a patient (Ludmerer, 1996).

Against this backdrop, in 1908, the Carnegie Foundationappointed Abraham Flexner to study the American medicaleducation system and suggest remedies. Flexners reportcalled or medical schools to be university based, oraculty to be engaged in original research, and or studentsto participate in active learning through laboratory studyand real clinical work (Flexner, 1925). Learning by doing

Historical context o medical education and migration




was the mantra he espoused, stating that the purpose omodern medicine was not to teach its students a large bodyo acts but to help them develop critical thinking and ascientic approach to clinical problems. Tese recommen-dations would subsequently inuence the development oAmerican medicine, which would become excellent and veryexpensive. Medical students henceorth would be taught byull-time academics called proessors, and medical schoolswould be supported by philanthropy. eaching hospitals

provided clinical resources to train medical students, andthe university hospitals conducted advanced research. Pro-prietary medical schools were closed, and by mid-1940s thepublic became aware o the major issues conronting medicaleducation. Te ederal governments nancial support orGME also became a reality because o public support.

Historically, there have been three important tenets oAmerican medicine: teaching, research and patient care.Te relative importance given to these three areas varied overtime. For example, the time between the World War I andWorld War II was seen as the era o teaching, in which many

innovations were introduced into medical education. In theearly 1900s, medical education ocused almost exclusively onundergraduate medical education leading to the MD degree,ollowing which the great majority o medical school gradu-ates entered general practice. By World War I, the bulk omedical knowledge had grown enormously, and our yearso education in medical school was elt to be inadequateto complete the curriculum. Tis necessitated a period obedside patient care experience and the internship wasborn. In the beginning, internship positions were availableonly to a handul o graduates. Te intern lived in dormitoriesprovided by the hospitals and worked in a hospital or a yearor two. However, they had limited clinical responsibilities andperormed menial tasks like working in the hospital labora-tories and transporting patients to diferent locations in thehospital. By the mid-1920s, the internship became availableor all medical school graduates and was transormed intoa true educational experience with a ull schedule o coner-ences, rounds and lectures, as well as the opportunity toparticipate actively in patient management.

Tere were three types o internships. Te most soughtater was the rotating internship, in which interns rotatedamong all the clinical areas. Te second was mostly associ-ated with medical schools that ofered straight internships

in medicine or surgery. Te third type was the emphasisinternship, in which the intern spent hal the time in one othe major disciplines and the other hal in a subspecialty.ypically, internships lasted one year, though some were aslong as three years. Te internship provided a well-roundedclinical experience as a preparation or general medical prac-tice. Residency training evolved mainly to develop academicscholars. In the beginning, unlike internship, which wasrequired o all medical school graduates beore they couldreceive a license to practice medicine, residency positionswere reserved or the elite. Ater completion o internship,only one-third o graduates were selected to enter residency

programs. Tis system o residency was introduced in theUnited States and patterned ater the system ollowed at theJohns Hopkins Hospital, which was based upon the system ohouse assistants, which originated in the medical clinics oGerman universities. Te Hopkins residency was designed tobe an academic experience or mature scholars.

Te Hopkins residency system is similar to the British systemo postgraduate training, and is also used in countries like

India, where postgraduate training is reserved or the crmede la crme o medical school graduates who wanted todedicate their career to research and teaching. Residentsevaluated patients themselves, made their own decisionsabout diagnosis and therapy, and perormed their ownprocedures and treatments. Tey were supervised by, andaccountable to, attending physicians. Te residency alsoemphasized scholarship and inquiry as much as clinicaltraining; it was the graduate school or clinicians. Residencycame to be recognized as the breeding ground or the nextgeneration o clinical investigators and medical scholars.

Coinciding with the support received rom the NationalInstitute o Health (NIH), the era rom World War II to 1965was considered the research era. With the passage o Medi-care and Medicaid in 1965, the clinical era began. However,the advent o managed care, which started in the late 1980sto correct deciencies in the health care system, was stressulon the academic medical centers. Now in 2010, exactly 100years ater Flexners report, a major reorm efort in healthcare delivery is again taking place in the United States withthe goal o providing health care or all Americans. Tisdevelopment will also have ar-reaching implications onmedical education, as well as elevate the need to train moredoctors to care or all the newly insured Americans.

Te ofshoot o Flexners report was a dramatic contraction inthe number o medical schools, which led to concerns aboutphysician shortages. In response, in the 1940s the SurgeonGenerals Consultant Group on Medical Education issued areport called the Bane Report, which projected a shortage o40,000 physicians by 1975 and recommended an increase inyearly graduates rom 7,400 to 11,000. Te report resulted inthe Health Proessionals Act o 1963, which, contingent uponan increase in class sizes by ve percent, provided existingschools ederal matching unds or the construction o neweducational acilities and marked the beginning o the edera

governments support o graduate medical education.

From 1960 to 1980, 40 additional medical schools werecreated. Simultaneously, there was an explosion in clinicalvolumes in teaching hospitals due to their reputation opossessing the latest technology and providing better patientcare. GME also underwent signicant changes during thisperiod called the democratization o the residency. BeoreWorld War II, only a minority o doctors became specialists.However, due to low prestige and income or general practi-tioners, there was a great demand or residency training inspecialties. Te increasing demand or specialization was




caused by the rapid expansion o medical knowledge andgrowing procedural complexity o medical practice thatresulted rom massive research eforts under way in medi-cine. Te clinical volumes also increased due to availabilityo private insurance. Medical schools aculties supportedexpansion o residency training because having residents onthe oors would provide them with time or research.

In addition, the shit rom the pyramidal system o residency

training to a parallel system, in which junior residentsprogressed up the ladder to become senior residents andgraduating to become board eligible, made residency traininga desirable goal or many medical students. While this wasgoing on, many community hospitals that are unaliatedwith academic medical centers ofered ree-standing intern-ships. As the demand or house ocers increased, a shortageor interns developed. In 1958, there were 12,325 internshippositions but only 6,861 graduates o American medicalschools. Accordingly, many hospitals lacking an aliationwith a medical school began to recruit IMGs to their healthstafs. Te number o IMGs increased rom 2,072 in 1950 to

9,457 in 1959. Since then, the anity between IMGs and theteaching hospital was established. In addition, these earlyembraces by teaching hospitals lead to the overwhelminglymajority o IMGs becoming clinicians in contrast toeducators and administrators.

As a result o the Bane Report, the number o allopathic andosteopathic medical schools rose rom 93 to 140, an increaseo 52 percent. Te number o graduates increased rom 7,000to 16,950 (+142 percent) by 1981. Just as the United Statesbegan to increase the numbers o home-grown physicians,it began to look to other countries to help meet its healthcare work orce needs, developing a legislative and regulatory

inrastructure to evaluate and process IMGs.

While these ar-reaching and undamental changes wereoccurring in America, the countries that would later becomesignicant sources o IMGs to the United States (India,Pakistan and the Philippines) were undergoing majorstruggles or independence rom their colonial rulers.For these countries, one o the benecial efects o theircolonial past had been their acility with English languageand the education systems o their ormer colonial powers.In medicine, this translated into the Western practices andeducation systems being inherited to orm a medical educa-

tion system that produced physicians in large number whowere little-suited to practice their Western-inuenced skillsand knowledge in their native lands. Tere was considerabledissonance between the real world and the curriculum in themedical school or these young physicians. Te physicianswho came out o this system were greeted by a social realitythat lacked the nancial wherewithal to utilize their skills,and emigration became a way out or many aspiring doctorsin these emerging post-colonial societies.

America welcomed these physicians to satisy a growingdemand. Tus, there was an initial synergy between theWest and the donor countries. When these IMGs arrivedin America, they quickly discovered they lacked the post-Flexnerian standards o scientic knowledge and skills andthereore they were relegated to the bottom o the two-tiersystem. Despite IMGs lacking some skills, they were essentialor the clinical mission o hospitals, and thereore the healthcare system continued to allow IMGs to enter the United

States. Te ollowing will describe the inrastructure that waselaborately constructed to acilitate the entry o IMGs intothe system.

Te Exchange Visitor Program has its origins in the UnitedStates Inormation and Educational Exchange Act o 1948,also known as the Smith-Mundt Act, and the Immigrationand Nationality Act o 1952. Beore the Smith-Mundt Act,exchange programs were conducted inrequently withonly a ew countries. With the goal o promoting betterunderstanding o the United States among the peoples othe world and strengthening cooperative international

relations, this legislation broadened the scope o exchangeconsiderably to include a wider array o countries. In 1961,the Mutual and Cultural Exchange Act, commonly knownas the Fulbright-Hays Act, expanded, strengthened, andbetter-dened exchange programs authorized in earlierlegislation. Te Fulbright-Hays Act authorized a wide rangeo cultural, technical and educational interchange activities.Te Exchange Visitor Program derives its authority rom thislegislation. Te Fulbright-Hays Act also established the J visa,the non-immigrant visa held by exchange visitors, whichenables oreign visitors to visit the United States toparticipate in educational and cultural exchanges.

During the 1950s, the need or a ormal program oevaluation o oreign medical graduate intensied due tothe explosive growth in the demand or health care services,and a greater dependence on physicians-in-training toprovide medical care. In 1954, the Cooperating Committeeon Graduates o Foreign Medical Schools (CCGFMS) wasormed by the Association o American Medical Colleges(AAMC), American Hospital Association (AHA), AmericanMedical Association (AMA), and Federation o StateMedical Boards (FSMB) as a rst step toward lling thisneed. In exploring methodologies that would uniormlyevaluate the qualications o oreign medical graduates,

CCGFMS recommended validating medical educationcredentials and creating examinations to evaluate skillsin the medical sciences and English language prociency.




In 1956, a private, non-prot organization, the EvaluationService or Foreign Medical Graduates (ESFMG) was ormed;it later changed its name to the Educational Council orForeign Medical Graduates (ECFMG). With the help o theNational Board o Medical Examiners (NBME) a medicalscience examination was developed. In March 1958, ECFMG

administered its rst medical science examination and test owritten English knowledge in 17 centers to 298 internationalmedical graduates. It was the unction o another body, theCommission on Foreign Medical Graduates, to monitor thevisa sponsorship o medical exchange visitors in the UnitedStates and to conduct research on IMGs. In 1965, theImmigration and Nationality Act (PL 89236) abolished nationalquotas and gave preerence to individuals with occupationsdesignated in short supply by the U.S. Department o Labor.Physicians were included on this list. Trough the ECFMG,examinations administered in many countries allowed U.S.residency training programs to recruit physicians rom all

over the world. International graduates chose the specialtyin which they wanted to obtain advanced training. Manyprograms paid or travel and accommodations. In 1974, theECFMG and the Commission on Foreign Medical Graduates,which monitored issuance o visas, merged to become theEducational Commission or Foreign Medical Graduates.

Te welcoming climate IMGs had previously enjoyed in theUnited States began changing in the mid-1970s. Te HealthProessions Education Assistance Act (HPEA) o 1976 (PL94-484) declared an end to the physician shortage. IMGs wereno longer given preerential visas that were meant or proes-sions with shortages. Among other requirements, the HPEAmandated specic examination requirements or oreign

national physicians. In response, an examination that metthe new requirements, the Visa Qualiying Exam (VQE), wasintroduced. Te VQE was essentially a shorter version o thethen current National Board o Medical Examiners (NBME)Part II & Part II examinations given to U.S. medical schoolstudents and graduates. Te VQE was replaced by the

Foreign Medical Graduate Examination in the MedicalSciences in 1984.

Beginning in 1989, IMGs were eligible to take the NBME PartI & Part II Examinations. Beginning in 1994, the United StatesMedical Licensing Examination (USMLE Steps 1, 2 and 3) wasrequired o both IMGs and USMGs or licensure in the UnitedStates. USMLE Step 1, Step 2 Clinical Knowledge (CK) and Step2 Clinical Skills (CS) are the current exams required or ECFMGcertication, a requirement or IMGs to enter graduate medicaltraining. Residency programs have diferent requirementsregarding completion o USMLE exams or USMGs. In 1999,the computer-based testing or all steps o the USMLE wasintroduced. ECFMG serves as the registration entity or IMGs orSteps 1, 2 CK and 2 CS. Steps 1, 2 CK and 3 are delivered by aprivate company, Tomson Prometric, through its worldwidenetwork. Steps 1 and 2 CK are administered in more than 50countries, including the United States and Canada. Step 3 isadministered in the United States and its territories only. Step 2CS is administered at ve centers in the United States. Between1958 and 2005, 656,813 candidates started the ECFMG certi-cation process and 292,287 (44.5 percent) eventually wereawarded the ECFMG certicate. Te number o candidatesseeking certication has ebbed and owed over the past 54years reecting the world situation, tightening o the immi-gration process, change o exam ormat and nancial cycles.

History o the ECFMG

Table 8

Milestones in the history o ECFMG

1958 The frst ECFMG medical knowledge examination, known as the American Medical Qualifcation (AMQ) Examination,is administered in 17 centers. The examination contains an English-language component, including an essay section.

1962 The AMQ is renamed the ECFMG Examination.

1969 The ECFMG assumes responsibility or administering the examinations, which had previously been administered by the NBME.

1972 The ECFMG reports examination results in a standard and scaled ormat similar to the NBME reporting ormat.

1974 A new ECFMG English test is introduced.

1977 The Visa Qualiying Examination (VQE) is developed by the NBME and administered by the ECFMG as equivalent to the NBMEPart I and Part II Examinations. The VQE is approved by the Secretary o Health, Education and Welare to satisy PL 94-484.

1979 A passing score on the English examination is determined by the ECFMG Board o Trustees to be valid or only two years or thepurpose o entering an accredited program o graduate medical education in the United States. Applicants who did not enter anaccredited program within two years o passing the English test were required to pass a subsequent English test to revalidatetheir Standard ECFMG Certifcate beore entering the residency program.

1981 The Federation Licensing Examination (FLEX) is accepted as an alternative examination or ECFMG Certifcation.

1984 The Foreign Medical Graduate Examination in the Medical Sciences (FMGEMS), developed by the NBME, replaces the ECFMGExamination and the VQE.

1989 The ECFMG begins administering the NBME Part I and Part II Examinations as an alternative to FMGEMS.

1992 The United States Medical Licensing Examination (USMLE) Step 1 and Step 2 Examinations are introduced.




Table 8

Milestones in the history o ECFMG (continued)

1993 FMGEMS is administered or the last time; it is replaced by the USMLE Step 1 and Step 2 Examinations.

1998 The ECFMG Clinical Skills Assessment (CSA) is introduced.

1999 Last paper and pencil administration o USMLE Step 2 Clinical Knowledge (CK) takes place in March 1999. Computer-basedtesting begins. The last ECFMG English Test is administered; this test is then replaced by the Test o English as a ForeignLanguage (TOEFL).

2004 The last ECFMG CSA is administered; it is replaced by the USMLE Step 2 Clinical Skills (CS) Examination. Eective with the

implementation o Step 2 CS in June 2004, all previously passed English tests used or ECFMG Certifcation were no longersubject to expiration or the purpose o entering a residency program, and TOEFL was eliminated as a requirement or ECFMGCertifcation

Hallock, Kostis; 50 years o ECFMG,Academic Medicine, 2006


able 9 below demonstrates the resilience o IMGs in thework orce by drawing their numbers against the backdrop omajor events that inuenced their ability to enter the UnitedStates. Whenever a change in policy concerning either thevisa or the examination ormat is announced, there is anupsurge in the number o candidates taking the ECFMG

examination. Once the anticipated change has occurred, the

numbers go down as the potential candidates adjust to thechange and nd loopholes in the system to enter the country.Over a period o a hal-century, it has become abundantlyclear that IMGs have become an integral part o Americanmedicine and that these events exert only a temporaryinuence on their numbers.

Table 9

First-time IMG PGY-1 residents and ECFMG certifcations

12,500

Certificatesan

d

PGY-1s

ECFMG Certicates

1982 1987 1992 1997 2002

10,000

7,500

5,000

2,500

0

1st time PGY1 IMGs

1976 Health ProfessionsEducation Act

1985 COBRArestrictions

1991 Expandedaccess to temporaryH1B Visas)

1992 Proposedexam change

1995 Computerizedexam

1998 CSAintroduced

ECFMG andJAMA

Cooper, 1995



Controversies in physician work orce recommendations

According to Mullan and others, the nations physician workorce will sufer rom the ollowing problems: too ew gen-eralists, too many specialists, too ew minority physicians,poor geographic distribution and a growing imbalance inphysician-population ratio (Mullan, 1995). According to theInstitute o Medicine, in 1970 the United States had a total o

308,487 physicians, or a ratio o 151.4 physicians per 100,000people. In 1992, the respective gures were 627,723 and 245.0,which represented an increase in the physician-to-populationratio o about 62 percent. Another important numberinvolved active physicians in patient care (excluding thosein training). In 1970, the gure was 220,657, with a physician-to-population ratio o 109.2 per 100,000; two decades later,the number was 461,405, giving a ratio o 180.1 physiciansper 100,000 population (an increase in the ratio o 65percent). Te Graduate Medical Education NationalAdvisory Committee concluded that the nation couldhave a physician surplus o 145,000 by the year 2000.

It is believed that the number o medical school graduateswho enter residency programs each year, and the specialtychoices they make, determine the uture size and specialtysize o the physician work orce. Physicians are responsibleor 70 to 90 percent o patients personal health care expen-ditures, and i the number o physicians increases healthcare expenditure will also increase (Grumbach, 1991). It hasbeen stated that health care expenditures consume about16.2 percent o the gross national product (www.hcfa.gov).Te cost containment concerns in the 1990s in the context othe growth o managed care, with its requirements or ewerspecialists and diminishing physician remuneration, addedgreater urgency to an examination o the question o thesize o the physician work orce. As mentioned beore,the number o IMGs in residency programs has increaseddramatically in the 1990s against the backdrop o theabove-described climate, and IMGs are seen to contributeto the increase in health care expenditures. As a result, manyleaders o medicine and policymakers seem to believe thatthe best way to curb the physician surplus is to reduce resi-dency positions and thereby reduce the numbers o IMGs.

Council on Graduate Medical Education

In 1997, the Council on Graduate Medical Education(COGME), which is authorized by Congress to provide anongoing assessment o physician workorce trends, trainingissues and nancing policies, stated that the current supplyo physicians was adequate; however, it ound that there weretoo many specialists and too ew generalists. It also oundthat there was an imbalance in physician distribution in ruraland inner-city areas. COGME recommended a 50/50 ratio ogeneralists/specialists and a cap in GME positions that wouldequal 10 percent over the total number o USMGs graduatingper year. It also recommended that the U.S. medical schoolenrollment not be increased.

COGME made specic GME nancing recommendations andadvocated or the creation o a National Physician WorkorceCommission to determine the appropriate number and mixo residency slots. It also included ambulatory sites in GMEreimbursement and recommended that an all-payer pool becreated to support GME where all stakeholders contribute.

Finally, it recommended creation o medical school consortiainvolving medical schools, teaching hospitals HMOs, andother teaching sites to nance and monitor GME.

Te impact o the recommendation related to the 10 percentadditional positions over the total number o USMGs orresidency positions would have led to an immediate reductionin the number o IMGs entering GME by approximately 75percent each year. Te reduction in specialists would have alsohad an adverse impact on IMGs who train in large numbers inspecialties. In addition, the creation o GME consortia undercontrol o medical schools with authority to distribute GMEunds would have shited the power away rom communityhospitals, where many IMGs train, to academic medicalcenters, which do not have as many IMGs.

Pew Health Proessions Commission

In 1995, Te Pew Health Proessions Commission believedthat the physician excess either already existed or soonwould exist in the United States and that there was an imbal-ance between generalists and specialists. It recommended a50-50 distribution o generalists and specialists and arguedor a 5 percent additional residency slot above the number oUSMGs. Te Commission believed there were problems with

physician maldistribution in inner cities and rural areas. Itmade specic GME nancing recommendations which calledor creation o a National Physician Workorce Commissionto determine the number and the ormulation o residencyslots. It also recommended that an all-payer pool be createdto und GME. In addition, it called or reducing the numbero both IMGs and USMGs in the U.S. health care work orce.It called or tightening o immigration laws to insure thatIMGs return home upon completion o training. Finally, itrecommended that by year 2005, the U.S. should reduce thenumber o students entering medical schools by 20 to 25percent. Tis reduction should come rom closing medical

schools and not by reducing class size.

Te implications o this report would have had a more drasticafect on IMGs because it called or a more severe cut inIMGs in residency positions. In many other aspects, theimplications are similar to those discussed with COGME.

A consensus statement

In 1997, the AMA, Association o American Medical Colleges,American Osteopathic Association, National Medical Associ-ation, Association o Academic Health Centers and AmericanAssociation o Colleges o Osteopathic Medicine endorsed a

http://www.hcfa.gov/http://www.hcfa.gov/



consensus statement on physician work orce.Te recommendations are as ollows:

Te number o entry-level positions in the countrys GMEsystem should be aligned more closely with the numbero graduates o U.S. medical schools and this reductionshould occur primarily through limits on ederal undingo GME positions.

GME opportunities should be provided or IMGs buttheir training should not be paid or by Medicare or byany national all-payer system that may be establishedin the uture.

Participating under J-1 exchange visitor program, IMGsare to return to their countries o origin.

o address the needs o underserved communities,the ederal government should provide incentives tomedical schools and students to encourage them tochoose careers as generalist physicians and to establishpractices in these communities.

Tere should be an all-payer GME und with transitionalpayments to teaching hospitals that lose residents andcreation o a national physician work orce advisorybody to monitor and assess the adequacy o size andcomposition o specialty physicians.

Te implications o these recommendations were ar-reaching since they had the backing o all the majororganizations in GME in the United States. It advocateduse o a GME nancing mechanism as a way o controllingGME positions. While ostensibly advocating training IMGsin the system, it created obstacles to their participation by

not providing nancial support or their training.

The Institute o Medicine

In 1995, the Institute o Medicine (IOM) appointed an expertcommittee to examine the question o the physician surplusin the United States. Te committee made the ollowingrecommendations:

Te number o positions in U.S. medical schools is keptat the same level. It rejected any attempt to lower theirnumbers.

No new medical schools should be opened, class sizesshould not be increased in the United States. Deliberatelydecreasing opportunities or young people o this countrybut not or those rom abroad is an unacceptable policy.

Federal support or GME should be revamped; medicaltraining should be separated rom patient care.

Place limitations on the training and entry into practiceo IMGs.

Ofer replacement unding or IMG-dependent hospitalsto permit them to serve the poor and the disadvantaged.

Collect and disseminate inormation regardingwork orce issues.

Te implications o this report explicitly recommendssevering the connection between patient care and residencytraining. Also, this report advocates a sons and daughterspolicy by encouraging U.S. citizens to enter medical educationand closing the doors to IMGs.

Managed careIn 2000, Weiner estimated the efects o health reorm onthe U.S. physician work orce requirement by extrapolatingcurrent patterns o stang within managed care plans tothe reshaped health care system. He assumed that 40 to 65percent o Americans will be under managed care plans bythen and that all citizens would have health coverage. Basedon these assumptions, he orecast the ollowing:

Tere will be an overall surplus o about 165,000 patientcare physicians.

Te requirement or and supply o primary care

physicians will be in relative balance.

Te supply o specialists will outstrip the requirementby more than 60 percent.

Weiner does not make any specic recommendationsregarding physician work orce (Weiner, 2000)

Whitcomb argues that there will be a physician surplusmainly contributed by IMGs and that mixed ree marketand regulatory approaches should be used to correct thisphysician imbalance. He believes that unless the entry o

IMGs is curtailed, no purpose would be served by loweringthe number o U.S. medical students. He recommends thatthe ederal government create an advisory body that deter-mines how many IMGs should be allowed into the systemeach year and distributes residency cards to qualied IMGsto participate in GME (Whitcomb, 1995).

Te implications rom Weiner and Whitcombs recommenda-tions would curtail any physician work orce expansion.

Reduce GME unding

Hospitals were incentivized nancially to reduce residency

positions by replacing residents with physician extenders.Tis last approach had never been tried beore until HealthCare Financing Administration (HCFA) launched the NewYork Demonstration Project (NYDP) in collaboration withGreater New York Hospital Association (Vladeck, 1997).Participation o hospitals was voluntary and the programbegan in two phases. Phase I started on July 1, 1997 andPhase II one year later. HCFA agreed to pay hospitals morethan $400 million as an incentive to signicantly reduce thenumber o residents in their programs. Te emphasis wouldbe on increasing the proportion o primary care residentsand reducing the number o specialists. In addition, the total




number o residents would have to be reduced over ave-year period in accordance with a ormula agreedupon, and there were penalties or early withdrawals.Te payments were intended to help the hospitals as theyreplaced residents with more expensive physician extenders.

When the program was announced, 42 hospitals joined withremarkable enthusiasm. However, it soon became clear tomany hospitals in New York area that it was impossible to

run clinical programs without residents. As a result, despiteonerous penalties, many hospitals withdrew rom the program.At the present, only a ew o the hospitals that originallyjoined the program have remained in it. Even though it wasnot the stated objective, the outcome o the project involvedan 11 percent reduction in the IMG component o thework orce in two years and a slight increase in the numbero USMGs.

Te Balanced Budget Act o 1997 consisted o provisions orreduction in GME support by HCFA, similar to NYDP (Educa-tion, 2000). It was a nationwide project, and hospitals weregiven transitional unds or reducing their resident numbers.Te act also reduced GME undingespecially the IndirectMedical Education Component (IME)over a three-yearperiod. For the purposes o calculating IME, it roze the numbero residents at a 1996-level. Tis act also led to considerablenancial diculties or many hospitals and Congress had topass amendments to restore unds to hospitals and make thereductions over a longer period o time

In 1999, the Medicare Payment Advisory Commissionreevaluated Medicares payment policies or GME andteaching hospitals (www.medpac.org), and recommendedthat Congress should try to inuence work orce policies

through targeted programs rather than through a reductiono GME programs.

In May 2009, Senator Bill Nelson (D-FL) introduced theResident Physician Shortage Reduction Act o 2009 in theU.S. Senate, and Rep. Joseph Crowley (D-NY) introducedidentical legislation in the U.S. House o Representatives.Tis bill proposes to amend itle XVIII o the Social SecurityAct to increase the number o Medicare-supported residencypositions across the United States by 15 percent, or approxi-mately 15,000 positions. Te bill also proposes changes in thedistribution o currently available positions and encouragesthe creation o new positions in primary care and generalsurgery programs. At the time o publication this bill isstill pending.

Physician work orce recommendation implications

Te aorementioned organizations and analysts believed thatthere would be a physician surplus in the oreseeable uture,that there was a shortage o primary care physicians and anexcess o specialists, and that IMGs would contribute to thatphysician surplus, and as a result, their continued entry intothe United States should be curtailed. Te impact o periodicchanges in the immigration laws and the ECFMG examinationprocess was to lower the number o IMGs. Te ECFMGexamination process has continually evolved over the years,as detailed later in this paper. Tis has been done periodicallysince the inception o ECFMG. Te most recent changeinvolved introduction o a new examination, the ClinicalSkills Assessment examination, which tests clinical skillsthrough encounters with standardized patients. Tis exami-nation was started in July 1998 and was administered only inPhiladelphia. Te location o the exam makes it dicult orIMGs because the U.S. consulates abroad do not readilyissue visas or IMGs to enter the United States to take anexamination. Additionally, the expense o a trip to theUnited States to take an examination without any guaranteeo a residency position is beyond the nancial reach o manyIMGs. As a result, the number o applicants entering theUSMLE process has diminished.

Bythe mid-2000s, it became apparent that the much-anticipated physician surplus had not materialized. In act,work orce analysts (led by Richard Cooper, MD) pointedout that by year 2020, the nation would experience a short-age o physicians. On the supply side, the ollowing actorswould contribute to ewer physicians: the baby boomersamong physicians were retiring; the increasing number oemale physicians, who work ewer number o hours than

their male counterparts; and an increasing preerence or aneasier liestyle by younger physicians. On the demand side,the ollowing were actors: increasing lie span, AIDS andother communicable diseases, and improved technology. Allo these actors would increase the demand or health care.Consequently, in 2005 to 2006, AAMC, COGME and HealthResources and Services Administration (HRSA) called orincreasing the output o U.S. medical schools, expressingconcern that unless the Medicare caps on residency programsare lited, there would not be an adequate number o physi-cians being trained. With an increase in the number o U.S.medical students and no increase in the number o residency

positions, the number o IMGs going into GME positionswould decrease.

http://www.medpac.org/http://www.medpac.org/



IMG contributions

Gap flling or saety net role

Gap lling or saety net roles are unique roles that deneIMGs position in the U.S. health care delivery system. Gaplling or saety net roles are the roles that many IMGs ulllin the physician work orce because they provide health careto underserved populations by entering specialties and

geographic areas that USMGs tend to avoid.

In a 1978 study, Politzer and others ound that IMGs aredistributed more evenly than USMGs and do not chooseareas where USMGs are located (Politzer, 1978). Mick andothers used distributional diferences to compare IMGsand USMGs along these our parameters:

Inant mortality rate

Socioeconomic status

Proportion non-white population

Rural county designation

In the states that had a large number o IMGs, the IMGswere located in areas where the our parameters existcompared to areas that had higher percentages o USMGswhere the our parameters did not exist or existed in smallerproportions. Te magnitude o these diferences was greateror IMGs than or USMGs, and there was a correlationbetween IMG disproportions and low physician-to-100,000population ratios. Mick and Lee ound that IMGs wererequently over-represented in counties where high inantmortality existed or where the physician-to-population ratiowas well below average (Mick et al., 2000).

Furthermore, a report prepared or the Bureau o HealthProessions on the distribution and proessional activitieso IMGs ound very strong evidence or the gap lling roleplayed by IMGs in American medicine (Mick et al., 1996).Te researchers ound that IMGs are concentrated incounties with the ollowing characteristics:

An inant mortality rate o 8.9/1,000 live births

An average to below average socio-economic status score

A per capita income o $16,800

A non-white population o greater than 12.5 percent

A 65+ population greater than 14.9 percent

A designation as a partially or ully healthproessions shortage

A non-metropolitan population o less than 50,000

A physician to population ratio o less than 120/100,000

More evidence o the vital role played by IMGs in the nationshealth care system comes rom a General AccountingOce Report that looked at the role o Exchange Visitor (EV)physicians in American medicine (GAO, 1996). Te J-1 visa isa temporary non-immigrant visa and those IMGs who are inthis category can apply to waive the requirement to return

to their home countries by working in a health proessionsshortage area (HPSA). Tis visa waiver route has become amajor source o physicians in rural and other HPSAs in theUnited States. Congress authorized the GAO to study thisphenomenon and submit a report. In its report, the GAOmade the ollowing observations that support the contentiono the gap lling unction o IMGs in American medicine.Te ndings relevant to the physician work orce debateare as ollows:

Governmental agencies requesting waivers or J-1physicians have become a necessary source o providingphysicians or undeserved areas. In 1994 to 1995, thenumber o waivers processed or these physicians equaledapproximately one-third o the total identied need orphysicians in the entire country and not in undeservedareas alone.

Te number o waivers rom governmental agenciesor physicians with J-1 visas to work in undeserved areashas risen rom 70 in 1990 to more than 1,300 in 1995,and 64 percent o these physicians completing GME in1995 chose to remain in the United States through thewaiver system.

Ninety percent o EV physicians complete their term otwo-year employment or these agencies, and 28 percento these physicians whose waivers were granted in 1990to 1992 were still practicing in those areas in 1996.

Te administrators o health care acilities in theseHPSA areas strongly support the visa waiver system. Suchadministrators oten turn to the visa waiver system as a lastresort once they ail to recruit USMGs or vacant positions.One administrator stated that the elimination o the waiversystem would be a travesty to health care in rural areas.

In specic areas o the country there is a very positive and

signicant concurrence between an IMGs native language,such as Spanish, and cultural amiliarity, and that o thespecic acilitys patient population. Te specialties seekingwaivers were internal medicine, pediatrics, amily medicine,obstetrics-gynecology, general practice and psychiatry, inthat order. It is noteworthy that 28 percent o IMGs whoseek these waivers continue to practice in these areas evenater ve years, whereas the retention rate or USMGs in theNational Health Service Corps is around 11 percent.

Salsberg and others ound that when comparing the post-residency career plans or IMGs and USMGs, IMGs holding




temporary visas are more likely than other IMGs topractice in health proession shortage areas (Salsberg, 2000).Baers and others ound that IMGs in rural areas constitutea greater percentage o U.S. primary care physicians in ruralareas with physician shortages than in rural areas withoutphysician shortages (Baers, 1998). However, they also oundthat there was substantial interstate variation in the extentto which IMGs practice in rural underserved areas. Mickand others (Mick, 1999) ound that IMGs serve in dispropor-

tionate numbers in cities, especially in the largest ones.

In another study about practice patterns o IMG and USMGpsychiatrists, Blanco and others ound that IMGs workedlonger hours, worked more requently in the public sectorand treated a higher proportion o patients with psychoticdisorders (Blanco, 1999). IMGs also received a higherpercentage o their income rom Medicaid and Medicarethan USMGs, whereas the reverse ratio was true or sel-payment by patients. Te authors caution that policies thatsubstantially decrease the availability o IMG psychiatristsmay adversely afect the availability o psychiatrists to treat

minorities and other underserved populations.Mullan and others believe that IMGs locate their oce-based practices similarly to USMGs with a slight IMG over-representation in the most densely populated counties anda slight under-representation in the non-metropolitancounties (Mullan, 1995). It is urther stated by Mullan thatIMGs ll residency and staf positions in smaller communities,but when they are ree to relocate to another practice atercompleting their training, they select the same urban-orien-tated pattern o communities as their USMG counterparts.In another study, Politzer and others applied the Gini indexo concentration (measure o inequality oincome orwealth)

to assess the geographic distribution o physicians and thecontribution o IMGs to improving or exacerbating thedistribution. Te authors ound that physician growth hasnot produced dividends in geographic distribution and thatIMGs generally worsen these distributions (Politzer, 1998).

Whitcomb and others determined the impact o limitingIMGs participation in the GME in the delivery o hospital careto the poor (Whitcomb, 1995). Tey ound only 77 out o 688hospitals to be IMG-dependent. Hence, the authors state thatthe IMG participation in service delivery to the poor may beoverstated. Salsberg and others ound in a study conducted

in New York, that ew o USIMGs and IMGs who are natural-ized citizens or permanent residents appear to go on to workin designated medically underserved areas and thus may notcontribute to the gap lling phenomenon (Salsberg, 2000).

In a study looking at the characteristics o patients cared or byIMGs, Hing and Lin ound that in 2005 to 2006, about one-quarter(24.6 percent) o all visits to oce-based physicians were toIMGs. Hispanic or Latino and Asian or Pacic Islander patientsmade more visits to IMGs (24.9 percent) than to USMGs (12.4percent). IMGS also saw a higher percentage o visits made bypatients expecting to use Medicaid or State Childrens Health

Insurance Program (SCHIP) as their primary payment source(17.6 percent) compared with USMGS (10.2 percent) (seeable 10). In 2005 to 2006, IMGs comprised 24.5 percent o alloce-based physicians. IMGs were more likely to be o Asianor Pacic Islander descent (31.6 percent compared with 4.9percent o USMGs) and Hispanic or Latino descent (6.7 percentcompared with 1.5 percent o USMGs). IMGs were more likely topractice in primary care shortage areas outside o metropolitanstatistical areas (67.8 percent) than USMGs (39.8 percent)

(Hing, 2009).

Table 10

Percentage o ofce visits to USMGs and IMGs by patient

race and ethnicity1

1.02.8

77.8

8.9

9.6

Non-Hispanic white

Hispanic or Latino

Asian or Pacic Islander

Other race or ethnicityNon-Hispanic black

1.4

63.8

9.9

16.8

8.1

U.S. medical graduates

International medical graduates

1 Statistically signifcant dierence between U.S. medical graduate and international medicalgraduate ofce visits. SOURCE: CDC/NCHS, National Ambulatory Medical Care Survey,20052006.

http://en.wikipedia.org/wiki/Income_inequality_metricshttp://en.wikipedia.org/wiki/Wealth_condensationhttp://en.wikipedia.org/wiki/Wealth_condensationhttp://en.wikipedia.org/wiki/Income_inequality_metrics



Table 11

Percentage o ofce visits to USMGs and IMGS by patients primary expected sources o payment1

0 10 20 30 40 50 60

All other sources

Self-pay, no charge or charity

Medicaid only

Medicare & Medicaid

Medicare only

Private insurance

U.S. medical graduates

55.2

46.6

21.9

22.4

1.6

3.4

8.6

14.2

4.3

4.7

8.4

8.7

International medical gradualtes

1 Statistically signifcant dierence between U.S. medical gradualte and international medical graduate ofce visits. SOURCE: CDC/NCHS, National Ambulatory Medical Care Survey, 20052006.

Te argument that IMGs cause surplus sufers rom severalmethodological issues. According to Mick, Te centralproblem in most o these studies is that they examinedaggregate national or state level data only and ignored possibledistributional diferences o IMGs and USMGs within theseboundaries (Mick, 2000). Tese gap lling studies examinethese work orce shortalls and have consistently shown thatIMGs redress physician shortages in Health Proessional

Shortage Areas (HPSAs). Te most thorough study conductedby the GAO, which lasted one year and involved site visits,interviews, and other thorough data collection methods,demonstrated a dire need or physicians in HPSAsa needthat IMGs are lling.

IMGs in primary care

An estimated 87 million people, one in every three Americansunder the age o 65, were uninsured at some point in 2007and 2008. One o the hardest-hit demographics in 2008were part-time workers. In 2008, 1.1 million lost their

health insurance, increasing the uninsured total or thisdemographic to 6.8 million. Compared to other industrializednations, the United States has a poor track record regardingthe delivery o primary health care services. More than 40million people lack health insurance and almost 20 percento the population lack a consistent provider o health care.Te public health inrastructure remains weak and mentalhealth care struggles or recognition and parity. Furthermore,the health care delivery system is highly ragmented when itneeds to be seamlessly integrated.

As a nation, the United States continues to struggle withdisparities in health and health care. Health care spendingis at an all-time high with estimates as high as $1.7 trillionspent annually, accelerating with a return to double-digitprice escalation in health insurance premiums during aperiod o economic slump. Te United States is in desperateneed o a better unctioning primary health care system, butour nations understanding o primary care is so rudimen-

tary that in 1996 the IOM ound it necessary to redene itsmeaning (www.annfammed.org/cgi/content/full/2/suppl_1/s3 - R30). Te IOM dened primary care as nota discipline or specialty but a unction as the essentialoundation o a su/ccessul, sustainable health care system.

Unortunately, the rate o growth in the subspecialty physicianpool has continued to ar exceed the growth rate in amilymedicine and other primary care specialties. Tis disparity isreected in the minimal growth o primary care physiciansper 1,000 population compared with the growth experiencedby non-primary-care specialists. Te 2007 Survey o Hospital

Physician Recruitment rends showed amily medicine asthe rst most heavily recruited specialty. Te physicianrecruiting company reported an 18 percent increase in amilymedicine recruitment contracts, with 43 percent o all hospitalsactively recruiting amily doctors. During April 2006 to March2007, amily medicine and general internal medicine werethe most requested physician assignments. Meanwhile, theinterest expressed by medical students in amily medicinehas declined to near crisis proportions, as reected in thedeclining resident match rates into amily medicine programs.

http://www.annfammed.org/cgi/content/full/2/suppl_1/s3%20-%20R30http://www.annfammed.org/cgi/content/full/2/suppl_1/s3%20-%20R30http://www.annfammed.org/cgi/content/full/2/suppl_1/s3%20-%20R30http://www.annfammed.org/cgi/content/full/2/suppl_1/s3%20-%20R30



Te results o the 2007 resident match showed a decrease or the eighth consecutive year in the number o U.S. seniors romallopathic medical schools selecting primary care. In internal medicine, the number o U.S. seniors held steady, comparedwith last year, as did ob-gyn, while pediatrics saw a small upswing. According to Perry Pugno, MD, MPH, director o the Amer-ican Academy o Family Physicians Medical Education Division, It is o concern that since 1988 amily medicine has reducedthe positions ofered by 511, while during that same period, U.S. medical school seniors selecting amily medicine declined by1,047. Currently, three out o ve rst-year residents in amily medicine are IMGs.

Table 12

Residency positions in amily medicine, 19942008

2008 2007 2006 2005 2004 2003 2002 2001 2000 1999

Positions oered 2,636 2,603 2,711 2,761 2,864 2,920 2,962 3,074 3,183 3,244

Positions flled 1,370 2,299 2,307 2,275 2,256 2,227 2,342 2,346 2,684 2,683

% flled 90.6% 88.3% 85.0% 82.4% 78.8% 76.2% 79.1% 76.3% 81.2% 82.7%

Filled by U.S.seniors

1,156 1,096 1,123 1,117 1,185 1,226 1,399 1,503 1,817 2,015

% Filled by U.S.seniors

43.9% 42.1% 41.4% 40.5% 41.4% 42.0% 47.2% 49.0% 57.1% 62.0%

1998 1997 1996 1995 1994

Positions oered 3,293 3,262 3,137 2,941 2,774

Positions flled 2,814 2,905 2,840 2,563 2,293

% flled 85.5% 89.1% 90.5% 87.1% 82.7%

Filled by U.S.seniors

2,179 2,340 2,276 2,081 1,850

% flled by U.S.seniors

66.2% 71.7% 72.6% 70.8% 66.7%

National Resident Matching Program, 2009

Te result o this disturbing trend is a health care deliverysystem that is severely compromised in its ability to meet

the growing primary care needs o our nation and is increas-ingly dependent on qualied IMGs to meet the acceleratingdemand or certied and skilled amily physicians.

Many communities rely heavily on IMGs or its primarycare needs. Civic leaders and work orce analysts are con-cerned that visa restrictions and limited J-1 visa waiversmay jeopardize the ragile health care delivery system.Te shortage may lead to economic ripple efects becausecompanies may not relocate in areas with limited accessto medical care or their employees and existing businessesmay lose qualied employees because they seek a better

quality o lie and improved medical care elsewhere.

IMGs are an indispensable part o a unctional primaryhealth care delivery system. Te United States needs tomake every efort to attract and retain qualied and skilledcandidates or this challenging eld o medicine. It is dicultto establish the total number o IMGs involved in deliveringhealth care to the U.S. population. Several medical organi-zations indicate that they either do not tally the numbero IMGs in their membership (e.g., the American Board oAnesthesiology), or do not record that inormation (e.g., theAmerican Board o Allergy and Immunology). However, data

collected by certain medical specialties validate the claimthat IMGs represent a signicant portion o physicians

providing care in various subspecialties.

Research by Salsberg published in theJournal o AmericanMedical Association (JAMA) suggested that IMGs, particularlythose with temporary visas, were more likely to train inprimary care specialties, internal medicine subspecialtiesand psychiatry than USMGs (Salsberg et al., 2000). IMGs tendto urther their skills by choosing specialization. Accordingto Salsberg and others research, IMGs with temporary visaswere more likely to subspecialize than were USMGs and84 percent were planning to practice in designated healthproessional shortage areas.

Te Bureau o Health Proessions, Health Resources andServices Administration submitted a report to the U.S.Congress entitled, Te Critical Care Work orce, whichindicated that the shortage o intensivists is getting worsedue to the inability o qualied IMG intensivists to remainin the United States because o visa restrictions. Tis reporturther indicates that a large proportion o critical careellows are IMGs.

Reportedly, there are 8,659 IMG diplomats certied by theAmerican Board o Family Medicine, which represents 12.6




percent o the total membership. Te American Board oAbdominal Surgery lists 3,170 IMGs as active members, ora total o 15.4 percent. Te American Board o Colon andRectal Surgery reports that 5.4 percent o its active diplomatsare IMGs. IMGs are especially well represented in the eld opsychiatry: 10,121, or 28 percent, o the membership o theAmerican Psychiatric Association are IMGs. O these, 7,151were born outside the United States. In act, according toa paper published in theAmerican Journal o Psychiatryin

March 1999, policies that substantially decrease the numbero IMG psychiatrists may adversely afect the availability opsychiatrists to treat minorities and other underserved popu-lations. A 2004 manuscript by Kostis and Ahmad, publishedin the Journal o Cardiology, indicated that among 156 activeprograms participating in cardiovascular disease match,22 percent o positions were taken by IMGs (Kostis, 2004).According to the authors, the percentage o clinical acultywho are IMGs has been stable, and IMGs account or approx-imately 25 percent o the U.S. physician work orce. It

imgs in american medicine - contemporary challenges and opportunities

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