0
Editorials: Point and Counterpoint |

COUNTERPOINT: Should the United States Provide Postgraduate Training to International Medical Graduates? No FREE TO VIEW

Jess Mandel, MD
Author and Funding Information

CORRESPONDENCE TO: Jess Mandel, MD, University of California, San Diego School of Medicine, 9500 Gilman Dr, Mail Code #0606, La Jolla, CA 92093


Copyright 2016, American College of Chest Physicians. All Rights Reserved.


Chest. 2016;149(4):895-897. doi:10.1016/j.chest.2016.01.009
Text Size: A A A
Published online

For many decades, international medical graduates (IMGs) have had a major role in staffing the health-care system of the United States. This occurs despite the great difficulty that non-citizens have in enrolling in US medical schools. Rather, many IMGs enter the US health-care system as postgraduate trainees at the residency or fellowship level. As an example, in the 2013 National Residency Match, IMGs comprised 36.8% of the 34,355 match registrants and 5,775 IMGs matched into their preferred specialties that year. IMGs comprise an even greater proportion of the fellowship application pool, representing 43% of applicants in 2011 to the adult subspecialties of cardiovascular disease; endocrinology, diabetes, and metabolism; gastroenterology; hematology and oncology; infectious diseases; nephrology; pulmonary and critical care medicine; and rheumatology; as well as neonatal-perinatal medicine.

Legal changes that permitted IMGs to pursue postgraduate training in the United States have resulted in many graduates remaining in the United States to practice: IMGs currently comprise approximately 25% of the US physician population. Between 1970 and 1994, the number of US medical school graduate physicians in the United States grew by 91.4%, whereas the number of IMG physicians increased by 170.2%. IMGs comprise over 35% of US internal medicine physicians and approximately 30% of psychiatrists, anesthesiologists, and pediatricians.

There is no doubt that IMG physicians contribute a great deal to US health care. The argument against continuing to provide postgraduate training to IMGs under our current system is not based on the quality of care that is delivered but rather on the problematic ethics of the current training environment, one that historically has not always held the best interests of IMG trainees paramount and which serves to retard the development and maturation of local medical capacity in the IMGs’ countries of origin.

The opportunities for IMGs to pursue postgraduate training in the United States began in the mid 20th century as the result of a large expansion of graduate medical education (GME) specialty training. Before the Second World War, only a minority of physicians became specialists. In the military during the war, physicians were not awarded rank, pay, responsibility, or access to preferred assignments on the basis of age and seniority, but rather on the basis of specialty training. As a result, the prestige of specialists was dramatically elevated whereas that of general practitioners was downgraded. More than two-thirds of military physicians indicated a strong desire to pursue specialty training after the war, as did sizable majorities of postwar US medical school graduates. Medical schools and teaching hospitals responded enthusiastically to this demand and the number of residency positions offered by US hospitals climbed from 5,796 in 1940 to 46,258 in 1970.

Although some of the reasons for dramatically expanding postgraduate training positions were altruistically related to improving the standards of American medicine, other reasons were more cynical. The increasing need for hospital services engendered both by technical advances and an increase in patients with private health insurance could be met quickly and relatively inexpensively by expanding the pool of postgraduate trainees. Resident-generated history and physical examinations and progress notes were permitted to serve as legal records and a culture was adopted in which attending physicians were rarely contacted about their patients outside of formal daily attending rounds. Relieved of the responsibilities of caring for inpatients on a continuous basis, senior physicians could focus their efforts upon additional compensated clinical work or upon research, which was receiving increasingly generous public funding.

As both academic and community-based hospitals recognized the tangible benefits that postgraduate trainees could provide, postgraduate training positions expanded with a momentum of their own and soon the number of available training slots exceeded the number of US medical graduates available to fill them. In 1958, US teaching hospitals sought to fill 12,325 approved internship positions, but US medical schools produced only 6,861 graduates that year.

IMGs were seen as an attractive means of sating the appetite of teaching hospitals for postgraduate trainees. Changes in American immigration law first permitted IMGs to train in the United States in 1948, the Educational Commission for Foreign Medical Graduates was established in 1956, and immigration reforms in 1965 resulted in easily obtainable visas for IMGs from poorer countries. To fulfill the needs of US teaching hospitals, the number of IMGs serving as interns or residents in the United States increased from 2,072 to 9,457 during the 1950s, and by the late 1960s 32% of US interns and residents were IMGs.,

Because the needs of training hospitals were paramount in the expansion of GME positions, serving the educational needs of IMGs has tended not to be a high priority. Despite efforts of accrediting bodies, the perception remains that many training programs with heavy IMG enrollment tend to to lack robust educational opportunities and instead focus on having IMG postgraduate trainees provide the clinical services necessary for economical and efficient functioning of their host institutions. As medical historian Kenneth Ludmerer wrote about residency programs at the end of the 20th century, “Top programs continued to attract mainly U.S. graduates; less competitive programs hired more international medical graduates or did not fill positions. House officers represented a good value to financially beleaguered hospitals.”

In a great many cases, the deficiencies of postgraduate training programs are tolerated by IMGs because they provide an opportunity ultimately to settle and practice in the United States. Thus, these training arrangements and their downstream effects create a “brain drain” of IMG physicians from their countries of origin, leading to significant loss of health capabilities in less developed countries. A 2005 study found that lower-income countries supply between 40% and 75% of the large number of IMGs (23% to 28% of all physicians) in the United States, United Kingdom, Canada, and Australia. The author of that study noted the “growing global concern about the large variation among the world’s nations in the availability of physicians and the negative impact of the scarcity of physicians on health equity, health disparities, and the fight against human immunodeficiency virus and AIDS,” and reported that sub-Saharan Africa, the Indian subcontinent, and the Caribbean were among the regions that experienced this phenomenon the most.

There are multiple negative effects from IMGs leaving their countries of origin for the United States and other developed nations. In addition to the loss of capable physicians, the countries of origin face financial losses from the lack of return on investments in education, may lose alignment between their local training programs and local health needs, and may experience a lowering of morale and deteriorating working conditions among the physicians who remain.,

Problems faced by the loss of local medical capacity when IMGs relocate to the United States or similar countries are of sufficient magnitude that the World Health Organization has developed the WHO Code of Practice on the International Recruitment of Health Personnel. The Code discourages the active recruitment of health-care workers from developing countries that are facing critical shortages of health personnel. It notes that “the recruitment of health personnel from developing countries facing shortages of health personnel reduces access to health care in those countries and exacerbates inequities between rich and poor and between urban and rural populations.”

Postgraduate training of IMG physicians in the United States grows out of a history of exploitation. It is indisputable that IMGs serve as valuable members of the US health-care workforce, but the use of IMG physicians in the United States selfishly serves our country’s health needs by inflicting the cost of reduced access to health care upon individuals who reside in less developed countries. The practice of constructing the US health-care workforce on the backs of less prosperous citizens of the developing world is deeply immoral and should not be continued. Postgraduate training in the United States for IMGs, their point of entry into the US health-care system in which many will ultimately spend their careers, needs to be reduced or eliminated. The nation should move to right-size the number of medical school and GME spaces available within the United States and adjust the specialty mix of training slots so that our nation becomes appropriately self-sufficient in meeting our own health-care needs. At the same time, rather than robbing less-developed nations of the valuable resource of their health-care providers, we need to form true international partnerships with them to develop high-quality, high-volume postgraduate training capacity within developing nations. It is wrong to perpetuate the status quo and continue to impair the health care received by some of the world’s most vulnerable individuals.

References

National Resident Matching Program and Educational Commission for Foreign Medical Graduates.Charting Outcomes in the Match for International Medical Graduates: Characteristics of Applicants Who Matched to Their Preferred Specialty in the 2013 Main Residency Match. 1st ed. January 2014.https://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=1&ved=0ahUKEwiwkpTV54zLAhUN5WMKHQT8CS0QFggdMAA&url=http%3A%2F%2Fwww.nrmp.org%2Fwp-content%2Fuploads%2F2014%2F09%2FCharting-Outcomes-2014-Final.pdf&usg=AFQjCNHJ1-Az4hFCXTSchaqaIaIQ9dUU5w&sig2=cmKsTpANwJp5T-tqqc7EHA. Accessed February 22, 2016.
 
National Resident Matching Program and Association of American Medical Colleges.Charting Outcomes in the Match: Specialties Matching Service, Appointment Year 2011. 1st ed. May 2013.http://www.nrmp.org/wp-content/uploads/2013/08/chartingoutcomessms2011.pdf. Accessed February 22, 2016.
 
American Medical Association. IMGs in the United States.http://www.ama-assn.org/ama/pub/about-ama/our-people/member-groups-sections/international-medical-graduates/imgs-in-united-states.page?Accessed September 24, 2015.
 
Ludmerer K.M. . Time to Heal: American Medical Education From the Turn of the Century to the Era of Managed Care.  1999;:180-195 [PubMed] Oxford University Press New York, NYjournal
 
Lippard V.W. . A Half-Century of American Medical Education.  1974;:96- [PubMed] Josiah Macy, Jr, Foundation (distributed by Independent Publishers Group) New York, NYjournal
 
Curran J.A. . Internships and residencies: historical backgrounds and current trends. J Med Educ. 1959;34:873-884 [PubMed]journal. [PubMed]
 
Ludmerer K.M. . Let Me Heal: The Opportunity to Preserve Excellence in American Medicine.  2014;:24- [PubMed] Oxford University Press New York, NYjournal
 
Mullan F. . The metrics of the physician brain drain. N Engl J Med. 2005;353:1810-1818 [PubMed]journal. [CrossRef] [PubMed]
 
Bundred P.E. .Levitt C. . Medical migration: Who are the real losers? Lancet. 2000;356:245-246 [PubMed]journal. [CrossRef] [PubMed]
 
Loefler I.J.P. . Medical migration. Lancet. 2000;356:1196- [PubMed]journal
 
World Health Organization.WHO Global Code of Practice on the International Recruitment of Health Personnel. May 2010.http://www.who.int/hrh/migration/code/full_text/en/. Accessed February 22, 2016.
 

Figures

Tables

References

National Resident Matching Program and Educational Commission for Foreign Medical Graduates.Charting Outcomes in the Match for International Medical Graduates: Characteristics of Applicants Who Matched to Their Preferred Specialty in the 2013 Main Residency Match. 1st ed. January 2014.https://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=1&ved=0ahUKEwiwkpTV54zLAhUN5WMKHQT8CS0QFggdMAA&url=http%3A%2F%2Fwww.nrmp.org%2Fwp-content%2Fuploads%2F2014%2F09%2FCharting-Outcomes-2014-Final.pdf&usg=AFQjCNHJ1-Az4hFCXTSchaqaIaIQ9dUU5w&sig2=cmKsTpANwJp5T-tqqc7EHA. Accessed February 22, 2016.
 
National Resident Matching Program and Association of American Medical Colleges.Charting Outcomes in the Match: Specialties Matching Service, Appointment Year 2011. 1st ed. May 2013.http://www.nrmp.org/wp-content/uploads/2013/08/chartingoutcomessms2011.pdf. Accessed February 22, 2016.
 
American Medical Association. IMGs in the United States.http://www.ama-assn.org/ama/pub/about-ama/our-people/member-groups-sections/international-medical-graduates/imgs-in-united-states.page?Accessed September 24, 2015.
 
Ludmerer K.M. . Time to Heal: American Medical Education From the Turn of the Century to the Era of Managed Care.  1999;:180-195 [PubMed] Oxford University Press New York, NYjournal
 
Lippard V.W. . A Half-Century of American Medical Education.  1974;:96- [PubMed] Josiah Macy, Jr, Foundation (distributed by Independent Publishers Group) New York, NYjournal
 
Curran J.A. . Internships and residencies: historical backgrounds and current trends. J Med Educ. 1959;34:873-884 [PubMed]journal. [PubMed]
 
Ludmerer K.M. . Let Me Heal: The Opportunity to Preserve Excellence in American Medicine.  2014;:24- [PubMed] Oxford University Press New York, NYjournal
 
Mullan F. . The metrics of the physician brain drain. N Engl J Med. 2005;353:1810-1818 [PubMed]journal. [CrossRef] [PubMed]
 
Bundred P.E. .Levitt C. . Medical migration: Who are the real losers? Lancet. 2000;356:245-246 [PubMed]journal. [CrossRef] [PubMed]
 
Loefler I.J.P. . Medical migration. Lancet. 2000;356:1196- [PubMed]journal
 
World Health Organization.WHO Global Code of Practice on the International Recruitment of Health Personnel. May 2010.http://www.who.int/hrh/migration/code/full_text/en/. Accessed February 22, 2016.
 
NOTE:
Citing articles are presented as examples only. In non-demo SCM6 implementation, integration with CrossRef’s "Cited By" API will populate this tab (http://www.crossref.org/citedby.html).

Some tools below are only available to our subscribers or users with an online account.

Related Content

Customize your page view by dragging & repositioning the boxes below.

Find Similar Articles
CHEST Journal Articles
PubMed Articles
  • CHEST Journal
    Print ISSN: 0012-3692
    Online ISSN: 1931-3543