Easing International Medical Graduates' Entry Into US Training

Abstract

Despite recent increases in the number of US medical graduates, international medical graduates (IMGs) constitute an important part of the US health care system and will continue to be needed to meet the nation's demands for medical services.1,2 Due to differences in culture, education, and local health care systems, IMG applicants and residents and the institutions preparing them for their professional careers experience financial, social, and political challenges, as well as personal, emotional, and financial hardships. We present the perspective of IMGs and provide practical suggestions for making the selection process and transition into US residency smoother and more efficient. This will better prepare this group for their training and service to their patients and, ultimately, the US health care system.Many IMGs who score high on the US Medical Licensing Examination (USMLE) ultimately do not train in the United States due to visa issues. These individuals often have spent considerable time and financial resources to take the examination prior to applying for a visa. A potential solution to this problem could be to require IMGs to obtain a visa or “pre-visa certificate” prior to taking the USMLE. In addition, making visa policies more lenient would help significantly.The 2003 implementation of the privacy provisions of the Health Information Portability and Accountability Act of 1996 (PL104-191) has made it more difficult for IMGs to obtain clinical observerships or externships to gain knowledge and experience of the US health care system. This is frustrating for applicants as most residency programs now require US clinical experience for applicants. Research is needed to explore the practical benefits of clinical observerships, particularly correlation with residents' future performance.Some programs, as the interview season progresses and they have a more complete picture of their applicant pool, send rejection notices to applicants requiring visas, indicating they will not sponsor visas. Programs should clearly state their visa policies and adhere to them so that IMGs can avoid experiencing lost time, energy, and funds and added mental stress.Although there is a debate about the value of US medical graduates' dean's letters,3 the dean's letter for many foreign medical schools uses a standard form rather than a personalized statement about the individual applicant. More weight should be given by program directors to the actual examination scores in medical school transcripts, which offer more information about graduates' academic performance.The National Residency Matching Program (NRMP) allows IMGs to opt out of the match. Many programs ask IMGs to use this option to secure the best candidates. This forces IMGs to choose between a residency spot and the opportunity to apply to a better and more desirable program. There is information that some programs offer IMGs an out of the match position and then withdraw the offer, leaving the candidate in limbo. There often are no repercussions to these actions, as IMGs are insecure and uncertain of their rights in the NRMP and their new country. More awareness among IMGs about their rights and more strict NRMP rules may provide a solution.Work-related stress in the first weeks of residency is immense, but IMGs also feel added stress, related to communication, social interaction, and acculturation. Once accepted into a US residency, IMGs should be provided with opportunities to improve their language, communication, and interpersonal skills and their ability to provide culturally competent care. Faculty who work with IMGs need added development to better prepare them for assisting this group to adjust to the US culture and health system.In summary, multiple opportunities exist to improve the hiring, match, and selection process for IMGs, as well as to enhance their training and acculturation of US practice after acceptance into a residency program. Transparency and adherence to a set of common guidelines will enhance IMGs' sense of fairness and satisfaction with the process of transitioning to a US residency. Research is needed to demonstrate the value of preparatory programs for IMGs to ensure they correlate with future performance and to enhance the content of these programs.The authors acknowledge Dr Janet A Jokela's support in reviewing and editing the initial version of the draft.