International medical school graduates in American medicine: is there the “dark side of the moon”?

Abstract

Sir, The percentage of international medical graduates (IMGs) in the US health care work force has been increasing steadily (1). Today, IMGs fill approximately one-third of Pediatric and Internal Medicine residency positions, and one-fifth of Family Medicine residency positions. Most IMGs come from non-English speaking countries, and are consequently confronted by a series of transcultural challenges that include not only language but also sex-role differences, lifestyles and culture (2). Sadly, little attention has been given to the emotional challenges encountered by IMGs in caring for patients – transculturally. Consequently, many emotionally charged issues that arise during graduate medical education are unrecognized and not addressed by the US training programs. Fiscella et al. assessed the transcultural challenges in caring for patients of IMGs and American medical graduates (AMGs) in a primary care residency program (2). Each resident wrote a narrative describing a challenging experience and facilitators then conducted a focus group to discuss these experiences. The written narratives were analyzed first. Themes of acceptance/rejection based on nationality seemed to predominate. For example, one IMG resident reported the following experience from a patient: “I do not want any doc who can not speak English taking care of me.” Another resident wrote: “The moment I entered his room, he (the patient) commented on my accent, which was all too much for him to accept.” One IMG wrote about how he feared being singled out if he made a mistake: “In the beginning, I had fear that I may be punished if I make a small mistake being foreigner.” Language emerged as a challenge particularly in communicating emotional support for patients. “I had difficulty expressing myself on different occasions. At times, I had difficulty understanding especially the inner city language and I have not been able to take an adequate history” an IMG wrote. Another IMG resident wrote about the potential for misunderstanding: “Sometimes the language barrier makes it difficult to ask a question in a way which is easily understood by patient and this communication gap sometimes gives wrong understanding of patient problem.” One IMG wrote about how his cultural background affected his ability to perform gynecologic examinations: “Coming from a culture where men do not perform a physical examination of a female patient, it is not easy to do female exam by a male physician especially breast and genitalia exam.” During the focus group, significantly, none of the IMG residents raised issues of discrimination or rejection; instead, the dominant theme of the discussion focused on providing emotional support transculturally. One IMG resident spoke of his inability to reassure a dying patient that it was his internship that caused him to feel depressed, and it was not the fault of the patient. “She wanted to know if she had done something that was making me so depressed. No, it is nothing with you. I just have too much work these days. I don't have much energy, and I can't communicate very well, and I am not very happy, but you have nothing to do with it.” Another IMG resident spoke of the effect on patient care of taboos regarding men touching women in his own culture. “Being from a culture as a female and male there is a difference. You cannot get too close. and so it can be very difficult sometimes for a foreign graduate to come into a culture where there is a difference between the different sexes.” Balon et al. (1) sought to determine if there is a selection bias against IMG applicants for USA residency training positions in psychiatry. Identical requests for a program application were sent by two resident applicants − one IMG and one graduate of a USA medical school − to 193 residency training programs, and the rate and character of responses were analyzed. The response rate to requests for an application form was significantly higher for the USA medical school graduate (159 responses) than for the IMG (87 responses). The quality of responses were also different in some cases. The authors concluded that some residency programs in psychiatry were attempting to limit the influx of IMG applicants at the very first level − the request for an application form. The reasons for this practice are not known, but discrimination could be a possible explanation. Today, at the onset of a new millennium, one in five physicians practicing medicine in the United States received their initial medical training in another country (2). There are multiple reasons why IMGs emigrate to the United States. These include the high regard for which the USA is held in terms of the quality of medical education, the quality of technological development and the commitment to biomedical research. Some countries train more physicians than their health care can absorb, while others may lack the facilities or expertise to train physicians in certain specialties or subspecialties. Frustration and/or dissatisfaction with advancement opportunities, financing arrangements, health care organization, and the political system may also contribute to physician migration across international borders. In addition, physicians practicing in the USA are perceived as being among the best compensated. For example, American physicians earn more than 3.2 times an Australian physician. It appears that educational and professional opportunities unavailable at home may be drawing force for many foreign-trained physician to the USA. Miller et al. (3) found that between 1994 and 1996 Australia and New Zealand lost over 1000 physicians to the United States. The United States, as a host/destination country, benefits by getting a pool of physicians that it did not train, while there is a loss of taxes that the donor country would not collect from them, not to mention the loss of services that they would have provided. However, despite the common sense aspect of this argument, the “brain drain” issue has rarely been studied and is probably more complex than it appears. Given the increasing number of IMGs in American hospitals, it seems clear that the USA has not discouraged physician influx (“brain drain”) despite problems that may be created for the nations from which they emigrated. Mullan et al. (4) argued that the estimated 5000 IMGs who enter the USA physician workforce each year represent the equivalent of the entire graduating classes of some 50 medical schools around the world. Most IMGs in residency training programs in the United States are not exchange visitors, but are either permanent residents or US citizens (4, 5). In general, IMGs gravitate toward initial residency programs in internal medicine and pediatrics, many of which have unfilled positions; however, they tend to subspecialize at a disproportionately high rate, reducing their net contribution to the generalist pool. A significant proportion of exchange visitors eventually enter into permanent practice in the United States, contrary to the intent of the J-1 visa-based residency training as an international educational exchange program.