International Medical Graduate Physicians Research Articles

Normalized “medical inferiority bias” and cultural racism against international medical graduate physicians in academic medicine

Socio-historical barriers remain a concern in Academic Medicine. Regrettably, despite the modern cultural era defined by increased recognition and response to such issues, widespread covert barriers and misperceptions continue to limit the advancement of many, in particular, international medical graduate physicians (IMGs) who represent a significant proportion of the US physician workforce. Adversity is experienced in the form of cultural racism, affinity bias, and underrepresentation in distinct specialties as well as in leadership roles. Often, these unnecessary hardships exacerbate pre-existing discrimination in Academic Medicine, further marginalizing IMGs. In this article, we discuss the prevalence of “medical inferiority bias” and the resulting impact on US healthcare, specifying considerations to be made from a policy perspective.

International Medical Graduate Resident Physicians in Psychiatry: Decreasing Numbers, Geographic Variation, Community Correlations, and Implications.

The number of International Medical Graduate (IMG) physicians matching into categorical psychiatry decreased steadily over the past decade. The authors sought to understand if this trend was occurring in other specialties, if US IMG physicians and non-US IMG physicians were equally affected, and if certain regions of the USA were more affected by this decrease than others. Finally, the authors compared the proportion of foreign-born individuals within a US census region to the proportion of non-US IMG physicians within that region. The authors analyzed data from the National Resident Matching Program from the years 2014-2020. Statewide data was aggregated into nine geographic regions, as per the US Census Bureau. The number of foreign-born individuals within each US census region was calculated from the 2018 American Community Survey data. In comparison to eight other specialties, psychiatry saw the greatest decrease (46.3%) in IMG physicians matching into PGY-1 positions. Both US IMG physicians and non-US IMG physicians were equally affected. The percentage of IMG physicians decreased in each of the nine US census regions. In six out of nine geographic regions, non-US IMG physicians were under-represented when comparing their proportion to the number of foreign-born people that lived within that region. Decreasing numbers of IMG physicians in psychiatry training may have long-term implications for cultural competency, serving underserved populations, and fellowship recruitment. We advocate for program directors to recognize IMG physicians as an important source of diversity and to recruit residents that reflect the communities they serve.

Healthcare Access in Medically Underserved Areas During the COVID-19 Era: An International Medical Graduate Perspective From a Rural State.

BackgroundPhysician shortage and healthcare access are serious issues in rural states like Kentucky and further worsened during the coronavirus disease 2019 (COVID-19) pandemic. International Medical Graduates (IMGs) serve the underserved communities of Kentucky to fill in the physician gap. However, uncertainties surrounding immigration policies added significant challenges to physicians and the rural communities served by them during the pandemic.MethodsA survey was created using the data collection platform “SurveyMonkey” and sent to IMG physicians practicing on a visa to understand their role and their immigration-related challenges. Only the physicians practicing in Kentucky were included in this study.ResultsIt was found that 84% practice in primary care specialties like internal medicine, pediatrics, or family medicine, 92.9% practice in Medically Underserved Areas or Health Professional Shortage Areas, and 71.4% practice in rural settings. Also, 61.5% practice in a “frontline” COVID-19 specialty and 92.3% were involved in direct care of COVID-19 infected or suspected patients. Of the physicians, 88.5% were in an “immigration backlog”; 92.6% of them were the primary visa holders of their families and 88.9% expressed concern that their families face hardship if they have a disability during the pandemic. It was reported by 92.3% of them that visa-related restrictions limited them from providing additional coverage in these places.ConclusionsLack of physician access is a critical issue facing many rural states in America like Kentucky, and IMG physicians play a valuable role in taking care of this underserved population and fighting the COVID-19 pandemic. The challenges surrounding the immigration backlog are contributing to significant hardships and remain a hurdle to expand healthcare access to the rural and medically underserved communities.

Deliberative versus nondeliberative evaluation of a minority group after viewing an entertainment portrayal

This study tests whether entertainment portrayals of international medical graduate physicians may influence attitudes toward such physicians among television viewers. Given the growing importance of international physicians in U.S. health care delivery, such effects would have the potential to impact significant numbers of patient–physician interactions. From a theoretical and methodological standpoint, this examination extends existing work on entertainment portrayals of often-stigmatized minorities and its impact on minorities for whom stereotypes may be in some respects favorable. An experiment manipulating positive versus negative portrayals of the communicative and professional competence of an Asian Indian female physician on the program ER found that exposure had no effect on conventional, deliberative measures of attitude toward such physicians. However, use of attitude-accessibility measurement suggested that viewers (to the extent that they identified with the narrative character, an Asian Indian physician) who saw the negative portrayal were slower to respond that they liked other Asian Indian female physicians who were presented in photos in a judgment task afterwards—in other words, the negative portrayal inhibited an approach response to other similar physicians. An implication of this finding is that such television portrayals may have the potential to influence affective responses to medical providers from the same demographic as the character portrayed, in ways viewers are likely to be unaware of. Such responses may well influence patient expectations and interactions with such physicians.

Attitudes towards latent tuberculosis among physicians in training: the role of BCG vaccination.

Prior work has demonstrated that international medical graduates physicians are less likely to recommend treatment of latent tuberculosis infection (LTBI) for themselves or their patients. Our objective was to measure differences in LTBI treatment attitudes among resident physicians when diagnosis is established with a positive tuberculin skin test (TST), as compared with a positive interferon gamma release assay (IGRA), and to determine whether a resident physician's personal history of Bacillus Calmette-Guerin (BCG) vaccination was associated with these attitudes. We conducted a cross-sectional survey of Internal Medicine resident physicians at two different training sites. Based on the country and year of birth, each respondent was assigned a putative BCG vaccination status based on a query of the BCG World Atlas (bcgworldatlas.org). We then asked whether the respondent agreed or disagreed with offering LTBI treatment in several clinical scenarios. Among their patients with a history of BCG vaccination, we found that resident physicians were least likely to agree with LTBI treatment for a first-ever positive TST, and most likely to agree with treatment for a converted IGRA. Contrary to our hypothesis, a resident physician's personal history of BCG vaccination was not associated with their LTBI treatment attitudes. Resident physicians broadly disagreed with LTBI treatment guidelines from the Centers for Disease Control and Prevention. Educational interventions designed to improve adherence to LTBI treatment recommendations should be broadly implemented, without regard to the educational or cultural backgrounds of physician.

Intergroup, Interpersonal, and Intercultural Nature of Patient–Provider Communication: A Comparison of IMG and USMG Physicians

Using communication accommodation theory as a framework, this study explores and compares communication patterns of international medical graduate (IMG) physicians and United States medical graduate (USMG) physicians in intergroup, interpersonal, and intercultural context. Given that every fourth doctor practicing medicine in the U.S. is an internationally trained physician (AMA-IMG, 2010) an examination of the influence on patient-provider communication involving IMG physician and comparison with USMG physician is warranted. In a national survey of IMG and USMG physicians, the participants self-reported their perceptions of communication behaviors they used during a medical interaction. Although no difference was found between IMG and USMG physicians use of communication accommodation strategies during medical interaction, IMG physicians reported practicing significantly more relational communication than their U.S. counterparts. USMG physicians reported greater difficulty in communication owing to differences in culture than IMG physicians. Implication of findings for patient-centered communication, patient-physician relationship, and communication skills training is discussed.

The “Brain Drain”: Factors influencing physician migration to Canada

Context: Higher income countries have an average physician density of 300 physicians per 100,000 people. In stark contrast, lower income countries have an average physician density of 17 physicians per 100,000 people. A major cause of this discrepancy is the migration of healthcare professionals from lower income to higher income countries, a phenomenon colloquially known as the “brain drain”. Objective: To explore factors that led International Medical Graduate (IMG) physicians to leave their home countries and migrate to Canada. Methods: An anonymous questionnaire with a mix of open- and close-ended questions was sent to 500 randomly selected IMG physicians practicing in Ontario, Canada. Results were analyzed using a mixed-method design utilizing both descriptive statistics and a thematic analysis approach. Results: 39 physicians met inclusion criteria and completed the survey. The majority were 50 years or older, and over 60% were male. The most common reason for emigration from their home country was the socioeconomic and/or political situation, and the most common reason for selecting Canada was family issues. Suggestions for how brain drain could be stemmed fell into three broad categories: 1) more accurate information about lack of opportunities in Canada, 2) more continuing medical education opportunities in home countries, and 3) address issues such as safety and quality of life in home countries. Conclusions: This survey provides insights into the reasons for emigration and immigration for international medical graduates. The results of this survey can assist stakeholders in working toward appropriate and acceptable solutions to the brain drain.

A closer look at Ontario's northern and southern rural physician demographics

In Ontario, Canada, there is a tendency to conflate rural and northern issues and although much of northern Ontario is rural, this is not exclusively the case. In this study, data were utilized from the licensing and regulatory body of physicians in Ontario to provide a more nuanced understanding of the distribution of the physician population across varying degrees of rurality in northern and southern regions. This is a report on the geographic distribution of the 22 688 GPs, and specialists certified by the College of Family Physicians of Canada and the Royal College of Physicians and Surgeons of Canada who had their primary practice address in Ontario. Descriptive statistics were produced to determine differences in distribution of physician numbers, age, sex, international medical graduates (IMGs), and certification for physicians with primary practices coded as northern versus southern across varying degrees of rurality. Differences were found in the Ontario physician population with regard to age, sex and IMG status between rural and urban areas and also from the northern versus southern perspective. There were more younger and male physicians in northern and rural areas. Female physicians were more frequently found in the south with decreasing proportions of females with increasing rurality. In the northern areas of the province, although the proportion of female physicians was lower than in the south, there was a slight increase in the proportion of female physicians as rurality increased. The largest proportions of IMGs were found in urban areas and the proportions of IMGs decreased with increasing rurality. However, northern rural regions did tend to have a higher proportion of IMG physicians than in corresponding rural areas in the south. The results indicate that although there are similarities in physician demographics in rural and urban areas, there are clear differences between the rural north and the rural south. Likewise, although some patterns distinguish the south from the north, these areas are not homogeneous regions where the urban north is clearly different from the rural north.

Professional Experiences of International Medical Graduates Practicing Primary Care in the United States

International medical graduates (IMGs) comprise approximately 25% of the US physician workforce, with significant representation in primary care and care of vulnerable populations. Despite the central role of IMGs in the US healthcare system, understanding of their professional experiences is limited. To characterize the professional experiences of non-US born IMGs from limited-resource nations practicing primary care in the US. Qualitative study based on in-depth in-person interviews. Purposeful sample of IMGs (n = 25) diverse in country of origin, length of practice in the US, specialty (internal medicine, family medicine and pediatrics), age and gender. Participants were currently practicing primary care physicians in New York, New Jersey or Connecticut. A standardized interview guide was used to explore professional experiences of IMGs. Four recurrent and unifying themes characterize these experiences: 1) IMGs experience both overt and subtle forms of workplace bias and discrimination; 2) IMGs recognize professional limitations as part of "the deal"; 3) IMGs describe challenges in the transition to the culture and practice of medicine in the US; 4) IMGs bring unique skills and advantages to the workplace. Our data reveal that IMGs face workplace challenges throughout their careers. Despite diversity in professional background and demographic characteristics, IMGs in our study reported common experiences in the transition to and practice of medicine in the US. Findings suggest that both workforce and workplace interventions are needed to enable IMG physicians to sustain their essential and growing role in the US healthcare system. Finally, commonalities with experiences of other minority groups within the US healthcare system suggest that optimizing IMGs' experiences may also improve the experiences of an increasingly diverse healthcare workforce.

Presidential Address: International medical graduates in the surgical workforce and the Veterans Affairs hospitals: where are We coming from? Where are We going?

The demand for physicians has fluctuated from shortages to oversupply, with reliance on international medical graduates (IMGs) during periods of shortages. Twenty-four percent of the total physician workforce and 20% of general surgeons are IMGs. To address an estimated shortage of 200,000 physicians by 2020 to 2025, a constant and stable supply of IMG physicians, in addition to greater numbers of graduating medical students is needed. General surgery, especially in underserved areas, will be severely affected, and little has been done so far to address this shortage. Over the years, Veteran Affairs hospitals have addressed physician shortages in their facilities by relying on IMGs despite mounting difficulties with visa sponsorship. A sensible solution is presented to address general surgery shortages in the United States while preventing global brain drain.

International Medical Graduate Physicians In The United States: Changes Since 1981

Nearly a quarter of all active U.S. physicians are international medical graduates (IMGs)--physicians trained outside the United States and Canada. We describe changes in characteristics of IMGs from 1981 to 2001 and compare them with their U.S. medical graduate (USMG) counterparts. Since 1981, the leading source countries for IMGs have included India, the Philippines, and Mexico. IMGs were more likely to be generalists and to practice in designated underserved areas than USMGs but slightly less likely to practice in isolated small rural areas and persistent-poverty counties. IMGs are an important source of primary care physicians in rural and underserved areas.

Evidence-Based Medicine

Evidence-based medicine (EBM)—with its focus on treatment approaches based on data and evidence, as opposed to intuition or clinical knowledge—goes to the heart of the differences between the education systems of the United States and many foreign countries. In order to emphasize a broader, patient-centered understanding and approach, EBM has evolved into evidence-based practice (EBP). This practice is a particular challenge for psychiatry, with its suboptimal diagnostic system and the extensive range of biopsychosocial–cultural–spiritual factors that move psychiatrists from generalities to an individualized understanding and treatment of patients. The institution, department, and teachers require strong commitment to effectively implement evidence-based psychiatric practice (EBPP) and help psychiatry residents become proficient in it. Although some international medical graduate (IMG) physicians are disadvantaged due to little or no previous exposure to the EBM paradigm, this disadvantage needs to be addressed with sensitivity. IMG physicians are clearly capable of delivering patient outcomes that are on par with those of graduates from medical schools in the United States.

International medical graduates in family medicine in the United States of America: an exploration of professional characteristics and attitudes

BackgroundThe number of international medical graduates (IMGs) entering family medicine in the United States of America has steadily increased since 1997. Previous research has examined practice locations of these IMGs and their role in providing care to underserved populations. To our knowledge, research does not exist comparing professional profiles, credentials and attitudes among IMG and United States medical graduate (USMG) family physicians in the United States. The objective of this study is to determine, at the time when a large influx of IMGs into family medicine began, whether differences existed between USMG and IMG family physicians in regard to personal and professional characteristics and attitudes that may have implications for the health care system resulting from the increasing numbers of IMGs in family medicine in the United States.MethodsThis is a secondary data analysis of the 1996–1997 Community Tracking Study (CTS) Physician Survey comparing 2360 United States medical graduates and 366 international medical graduates who were nonfederal allopathic or osteopathic family physicians providing direct patient care for at least 20 hours per week.ResultsCompared to USMGs, IMGs were older (p < 0.001) and practised in smaller (p = 0.0072) and younger practices (p < 0.001). Significantly more IMGs practised in metropolitan areas versus rural areas (p = 0.0454). More IMG practices were open to all new Medicaid (p = 0.018) and Medicare (p = 0.0451) patients, and a greater percentage of their revenue was derived from these patients (p = 0.0020 and p = 0.0310). Fewer IMGs were board-certified (p < 0.001). More IMGs were dissatisfied with their overall careers (p = 0.0190). IMGs and USMGs did not differ in terms of self-rated ability to deliver high-quality care to their patients (p = 0.4626). For several of the clinical vignettes, IMGs were more likely to order tests, refer patients to specialists or require office visits than USMGs.ConclusionThere are significant differences between IMG and USMG family physicians' professional profiles and attitudes. These differences from 1997 merit further exploration and possible follow-up, given the increased proportion of family physicians who are IMGs in the United States.

The role of international medical graduates in America's small rural critical access hospitals.

Critical access hospitals (CAHs) are a federal Medicare category for isolated rural facilities with 15 or fewer acute care beds that receive cost-based reimbursement from Medicare. This study examines the role of foreign-born international medical graduates (IMGs) in the staffing of CAHs. Chief executive officers (CEOs) of CAH facilities answered a telephone survey on their use of IMGs and the characteristics of those IMGs in winter 2002 (388 responded, for a 96% response rate). This descriptive report presents roles and characteristics of IMGs in CAH facilities and the opinions of the CEOs about these practitioners. Overall, 1 (24%) in 4 admitting physicians in CAHs are graduates of non-US medical schools (compared with 23% of physicians nationally), although the rates are higher for CAHs in persistent poverty counties, CAHs that report recruitment problems, and CAHs with smaller medical staffs. Hospitals east of the Mississippi River are more heavily reliant on IMGs than hospitals in the west. Most IMGs are internists (59%) and most (61%) come from India, the Philippines, or Pakistan. Hospital administrators rate the clinical skills of their IMGs highly and their interpersonal skills only slightly lower. Almost half of CAH administrators said their communities recruited their first IMGs during or after 1994, the year of pro-IMG legislative changes. IMG physicians play a significant and possibly growing role in staffing CAHs.

Initial practice locations of international medical graduates.

To examine the influence of place of graduate medical education (GME), state licensure requirements, presence of established international medical graduates (IMGs), and ethnic communities on the initial practice location choices of new IMGs. The annual Graduate Medical Education (GME) Survey of the American Medical Association (AMA) and the AMA Physician Masterfile. We identified 19,940 IMGs who completed GME in the United States between 1989 and 1994 and who were in patient care practice 4.5 years later. We used conditional logit regression analysis to assess the effect of market area characteristics on the choice of practice location. The key explanatory variables in the regression models were whether the market area was in the state of GME, the years of GME required for state licensure, the proportion of IMGs among established physicians, and the ethnic composition of the market area. The IMGs tended to locate in the same state as their GME training. Foreign-born IMGs were less likely to locate in markets with more stringent licensure requirements, and were more likely to locate in markets with higher proportions of established IMG physicians. The IMGs born in Hispanic or Asian countries were more likely to locate in markets with higher proportions of the corresponding ethnic group. Policymakers may influence the flow of new IMGs into states by changing the availability of GME positions. IMGs tend to favor the same markets over time, suggesting that networks among established IMGs play a role in attracting new IMGs. Further, IMGs choose their practice locations based on ethnic matching.