0
Editorials: Point and Counterpoint |

POINT: Should the United States Provide Postgraduate Training to International Medical Graduates? Yes FREE TO VIEW

Richard Allman, MD; Apostolos Perelas, MD; Glenn Eiger, MD
Author and Funding Information

CORRESPONDENCE TO: Apostolos Perelas, MD, Department of Medicine, Einstein Medical Center Philadelphia, 5501 Old York Rd, Klein Bldg, Ste 331, Philadelphia, PA 19141


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


Chest. 2016;149(4):893-895. doi:10.1016/j.chest.2016.01.011
Text Size: A A A
Published online

We will argue that the best interest of American graduate medical education (GME) and the US health-care system will be served by continuing to provide training to graduates of international medical graduate (IMG) schools.

Our argument rests on four major points: (1) IMGs already contribute a significant percentage of physicians in the United States as well as those in graduate medical training including internal medicine, pulmonary, and critical care; (2) we face an impending physician shortage; (3) IMGs represent the most viable solution to fill vacancies in GME and eventually enter the US health-care workforce, including clinical practice in underserved areas; (4) highly qualified persons from other countries are welcomed into many segments of American society such as science, technology, higher education, the arts, and athletics; medicine should not be an exception.

IMGs occupy a significant place in the US health-care system. In an American Medical Association-IMG position article, Cohen was quoted as saying “IMGs …have improved health care delivery, provided care to underserved populations, made groundbreaking discoveries in biomedical research, introduced new surgical techniques, pioneered innovative teaching methods, and more.” IMGs participate as members and leaders of the American College of Chest Physicians (CHEST). In 2007, 243,457 IMG physicians represented 26% of the total number of physicians in the United States. In certain geographic regions such as New York and New Jersey, IMGs represent over 40% of the physician workforce. The largest percentage of IMGS is in the specialties of internal medicine (37%), psychiatry (32%), pediatrics (28%), and family medicine (27%), in which the greatest shortages of providers occur. Previous reports show that many IMGs enter specialties and provide health care to areas and underserved populations that may not be attractive to US medical graduates.,,,

The 2015 National Residency Matching Program was the largest match in history, as reflected by the number of positions offered and filled: the highest number ever, 3,641 non–US citizen IMGs were matched. In 2015, there was a total of 67.3% of foreign-trained physicians (both US and non-US IMG) matched with positions in internal medicine, family medicine, and pediatrics. A larger percentage of foreign-trained physicians have been matched to internal medicine every year since 2011. In 2015, 43.9% matched to internal medicine. Of the 6,698 filled positions in internal medicine, 41.3% were foreign-trained physicians.

The 2015 fellowship match was also the largest in the history of the Specialties Matching Service. Of the 8,503 positions, 87.8% were filled. Twenty-three specialties filled 50% or less of positions with US allopathic graduates. For the subspecialties of internal medicine, IMGs (US and Non-US) accounted for 29.5% to 65.2% of positions filled. Pulmonary critical care fellowships had 40% of positions filled with IMGs, and interventional pulmonology, 65.2%.

The American health-care system faces an impending physician shortage. A solution must be expeditiously identified, given the long process of physician training and specialization. Although aggressive measures have been undertaken, including an increase in the number of US medical schools and the size of medical school classes, multiple demographic factors will cause the demand for physicians to outstrip the supply significantly. In 2025 the projected shortfall for physicians in the United States is between 46,100 and 90,400, including primary care and non-primary care providers. To address this shortage, an expansion in GME positions is necessary. If this occurs, a greater need will exist for IMGs to fill many subspecialty positions.

The personnel issue in critical care reflects the situation facing the rest of the medical profession but may be even more severe. The Committee on Manpower for Pulmonary and Critical Care Societies (COMPACCS) in 2000 projected a decrease in the proportion of care provided by intensivists and pulmonologists. A 2006 report to Congress documented a need to increase intensivist supply. Alternatives to directly provided intensivist care include midlevel providers, e-ICU, or hospitalists; whether these models are safe, sustainable, cost-effective, and successful is debatable. Even if alternative models are applied, optimal care may be unavailable for the most vulnerable critically ill patients. IMGs contribute significantly to our current critical care workforce at the fellowship and provider levels and are an important source of physicians to help meet the shortfall of intensivists.

Continued deployment of international graduates into our training programs and workforce cannot or should not be the only strategy for addressing the workforce shortage. The number of GME training slots must also increase. However, the fact is that insufficient numbers of US graduates have opted to enter training programs in many specialties.

Although more US graduates are entering GME and the workforce, it is uncertain whether they will choose to enter practice in the less desirable specialties and areas, including rural and inner-city settings or in areas where amenities, climate, housing, and lifestyle questions make such career options less attractive. We must acknowledge the American article of faith that militates against graduates going to areas of greatest need. A cultural individualism resists being told where one can live and work. A sense of entitlement to “the good life” exists for students who have invested so much time and treasure into their education. A job market restricted to less desirable areas could undermine the attractiveness of certain specialties and medicine in general. A concern that must be entertained is that greater numbers of US medical students could make admission less competitive as the supply of and demand for medical school admission slots come into greater balance. Will medicine be better served by a greater supply of possibly less qualified US graduates than the elite IMGs who have been carefully screened for entry into the US GME system?

The increase of the number of graduates of US medical schools cannot necessarily fill the gaps in either numbers or geographic distribution. Increasing numbers of US graduates will not necessarily choose careers in underserved specialties. We, like many others, hope for an expansion in GME positions. A critical mass of residents and fellows is needed for the educational mission of training programs, curricular needs, and patient care needs for the complicated patients seen in US teaching hospitals. The pool of US graduates is unlikely to meet this programmatic need successfully.

In our current political culture, a mean-spirited streak of nativism and xenophobia is present. Should medical education embrace that or does the altruistic tradition of medicine call upon us to be better than that? We embrace our nation’s historic heritage as a place that welcomes strangers, especially those willing to work hard and provide services that collectively make us better.

None of this minimizes the task of preparing international graduates for entry into a system that is clearly different from that in many of their countries of origin. In addition, our system must be sensitive to its contribution to a “brain drain” in the countries of origin of so many of our finest IMGs. Furthermore, consideration of the role of graduates of the medical schools in the Caribbean is necessary, schools that historically accept many US citizens who have not been accepted into US allopathic or osteopathic schools. As a society, we must commit to encouraging some of the best of our IMGs to consider returning to their country of origin, and to developing excellent programs. This can enhance care in underserved parts of the world and globally nurture admiration for our nation and medical educational system. We also must recognize that a reason for emigration to the United States is the opportunity to engage in care that regrettably is beyond the resources of many developing nations.

The contribution of IMGs has been and will be enormous to clinical practice, education, and research. Despite the professional, intellectual, and scientific fulfillment for those who practice medicine, the shortage of trainees will continue, as will the maldistribution for reasons that are distinctly American. Addressing that shortage by limiting the entry of excellent and worthy IMGs will only exacerbate the problem and diminish us as a nation.

References

American Medical Association-International Medical Graduates Section Governing Council. International Medical Graduates in American Medicine: contemporary challenges and opportunities. Position paper. January 2010.
 
Mick S.S. .Lee S.Y. .Wodchis W.P. . Variations in geographical distribution of foreign and domestically trained physicians in the United States: “safety nets” or “surplus exacerbation”? Soc Sci Med. 2000;50:185-202 [PubMed]journal. [CrossRef] [PubMed]
 
Mick S. .Lee S. . An analysis of the comparative distribution of active post resident IMGs and USMGs in the United States in 1996. Report to the Bureau of Health Professions, Health Resources and Services Administration.  1996;:- [PubMed] University of Michigan Rockville, MDjournal
 
Salsberg E. .Nolan J. . The post training plans of international medical graduates and U.S. medical graduates in New York State. JAMA. 2000;283:1749-1750 [PubMed]journal. [CrossRef] [PubMed]
 
Hing E. .Lin S. . Role of international medical school graduates in providing office-based medical care: United States, 2005–2006. NCHS data brief no 13.  2009;:- [PubMed] National Center for Health Statistics Hyattsville, MDjournal
 
Results and Data 2015 Main Residency Match, April 2015.http://www.nrmp.org/wp-content/uploads/2015/05/Main-Match-Results-and-Data-2015_final.pdf. Accessed October 4, 2015.
 
Results and Data Specialties Matching Service 2015 Appointment Year, February 2015.http://www.nrmp.org/wp-content/uploads/2015/02/Results-and-Data-SMS-2015.pdf. Accessed October 4, 2015.
 
  March 2015;:- [PubMed] Association of American Medical Collegesjournal
 
Iglehart J.K. . The residency mismatch. N Engl J Med. 2013;369:297-299 [PubMed]journal. [CrossRef] [PubMed]
 
Agnus D.C. .Kelley M.A. .Schmitz R.J. .White A. .Popovich J. . Caring for the critically ill patient: current and projected workforce requirements for care of the critically ill and patients with pulmonary disease: can we meet the requirements of an aging population? JAMA. 2000;284:2762-2770 [PubMed]journal. [CrossRef] [PubMed]
 
US Department of Health and Human Services, Health Resources and Services Administration report to Congress. The critical care workforce: a study of the supply and demand for critical care physicians.http://bhpr.hrsa.gov/healthworkforce/reports/studycriticalcarephys.pdf. Accessed October 4, 2015.
 
Mullan F. . The metrics of the physician brain drain. N Engl J Med. 2005;353:1810-1818 [PubMed]journal. [CrossRef] [PubMed]
 
Eckhert N.L. .van Zanten M. . U.S.-citizen international medical graduates—a boon for the workforce? N Engl J Med. 2015;372:1686-1687 [PubMed]journal. [CrossRef] [PubMed]
 

Figures

Tables

References

American Medical Association-International Medical Graduates Section Governing Council. International Medical Graduates in American Medicine: contemporary challenges and opportunities. Position paper. January 2010.
 
Mick S.S. .Lee S.Y. .Wodchis W.P. . Variations in geographical distribution of foreign and domestically trained physicians in the United States: “safety nets” or “surplus exacerbation”? Soc Sci Med. 2000;50:185-202 [PubMed]journal. [CrossRef] [PubMed]
 
Mick S. .Lee S. . An analysis of the comparative distribution of active post resident IMGs and USMGs in the United States in 1996. Report to the Bureau of Health Professions, Health Resources and Services Administration.  1996;:- [PubMed] University of Michigan Rockville, MDjournal
 
Salsberg E. .Nolan J. . The post training plans of international medical graduates and U.S. medical graduates in New York State. JAMA. 2000;283:1749-1750 [PubMed]journal. [CrossRef] [PubMed]
 
Hing E. .Lin S. . Role of international medical school graduates in providing office-based medical care: United States, 2005–2006. NCHS data brief no 13.  2009;:- [PubMed] National Center for Health Statistics Hyattsville, MDjournal
 
Results and Data 2015 Main Residency Match, April 2015.http://www.nrmp.org/wp-content/uploads/2015/05/Main-Match-Results-and-Data-2015_final.pdf. Accessed October 4, 2015.
 
Results and Data Specialties Matching Service 2015 Appointment Year, February 2015.http://www.nrmp.org/wp-content/uploads/2015/02/Results-and-Data-SMS-2015.pdf. Accessed October 4, 2015.
 
  March 2015;:- [PubMed] Association of American Medical Collegesjournal
 
Iglehart J.K. . The residency mismatch. N Engl J Med. 2013;369:297-299 [PubMed]journal. [CrossRef] [PubMed]
 
Agnus D.C. .Kelley M.A. .Schmitz R.J. .White A. .Popovich J. . Caring for the critically ill patient: current and projected workforce requirements for care of the critically ill and patients with pulmonary disease: can we meet the requirements of an aging population? JAMA. 2000;284:2762-2770 [PubMed]journal. [CrossRef] [PubMed]
 
US Department of Health and Human Services, Health Resources and Services Administration report to Congress. The critical care workforce: a study of the supply and demand for critical care physicians.http://bhpr.hrsa.gov/healthworkforce/reports/studycriticalcarephys.pdf. Accessed October 4, 2015.
 
Mullan F. . The metrics of the physician brain drain. N Engl J Med. 2005;353:1810-1818 [PubMed]journal. [CrossRef] [PubMed]
 
Eckhert N.L. .van Zanten M. . U.S.-citizen international medical graduates—a boon for the workforce? N Engl J Med. 2015;372:1686-1687 [PubMed]journal. [CrossRef] [PubMed]
 
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