International Medical Graduates Research Articles

Distribution of international medical graduates across USA surgical training programs: a descriptive cross-sectional study.

International medical graduates (IMGs) have been a critical part of the USA healthcare in the past 30 years, especially in small rural and poor counties. However, little to no publications are present on the distribution of these IMGs across general surgery residency programs. All freely accessible information on current residents in accredited general surgery residency programs within the USA with at least a 5-year history was explored for IMGs in the current roster using the AMA residency and fellowship database in 2020. Demographic and geographic data were summarized. A total of 230 general surgery residency program were included. Programs were distributed among 46 (92%) states. Of a total 6304 categorical general surgery residents, 573 (9%) were IMGs. Florida (USA) had the highest total number of current IMG general surgery residents with 64. The highest percentage of current IMG residents was found in Maryland (USA) with 31%. IMGs obtained their medical degrees from 76 different countries worldwide. Grenada was the country with the highest origin of IMGs with 77 residents. Central/North America had the highest origin of IMGs with 217 (38%). IMGs make up a small portion of current general surgery residents in USA programs. Some states host more IMGs than others. Particular countries have contributed more IMGs than others. More research is needed to the challenges facing IMGs and come up with novel solutions for them.

Workforce: Acculturation of international medical graduates into the NHS

Since the inception of the NHS, international medical graduates (IMGs) have been recognised as integral to the NHS long-term plan. These diverse groups of doctors make up approximately a fifth of all licensed doctors in the UK. The NHS has a history of reliance on IMGs to fill shortages and add to the workforce. IMGs face numerous challenges while immigrating and starting a new job in the UK. Conversely, the employing hospital has a responsibility to help their new IMGs adapt to the UK system of medical practice. Keeping the above-mentioned concerns in mind and hoping to tackle these issues faced by IMGs, a clinical attachment programme has been initiated at Ashford and St Peter's Hospitals NHS Foundation Trust (ASPH) by a group of clinicians, administration staff and the medical director. Although there are various pathways for an IMG to enter the healthcare system in the UK, the ASPH has provided an organised programme that promises to deliver high-quality doctors that value patient safety. This article outlines the programme that can be adopted by other NHS trusts to acculturate and have a positive impact on the IMGs' careers, as well as their work-life balance.

Immigrant Doctors and the Transnational Roots of Canadian Medicare

Immigrant Doctors and the Transnational Roots of Canadian Medicare Alex Myrick (bio) IN A RECENT FRONT-PAGE STORY published by the Telegram in St. John’s, Newfoundland, journalist Peter Jackson observed that only one 2021 Memorial University of Newfoundland medical school graduate has agreed to establish a practice in the province. Jackson states that this news comes at a time when “several existing family physicians” are reducing their practices or are retiring all together.1 According to Jackson, the lack of new doctors, and the retirement of the older ones, are adding to the province’s impending doctor shortage. During a recent visit to St. John’s, federal Immigration Minister Marco Mendicino stated “One of the ways that we can provide reinforcements to the front lines of the health care sector is through immigration.”2 Mendicino’s comment reflects the current federal government’s recognition of a much publicized doctor shortage, and that immigration may provide a solution.3 But while journalists are helping to raise awareness of this issue, the historic root causes are left unexamined. Fortunately, two of Canada’s most accomplished historians of medicine, Sasha Mullally of the University of New Brunswick and David Wright of McGill University, have published Foreign Practices: Immigrant Doctors and the History of Canadian Medicare. The central purpose of their text is to examine the immigration of foreign-trained doctors to Canada following the Second World War and the vital role they played in the delivery of health services during the transition to Medicare during the late 1960s and early 1970s.4 To frame this narrative, Mullally and Wright focus on the years between 1957 [End Page 117] and 1984 as immigrant physicians established themselves throughout Canada. Mullally and Wright primarily argue, as a result of their study of the links between immigration and health care, that universal health insurance in Canada was able to survive because of the influx of foreign-trained doctors, who bolstered the nation’s ability to deliver health services to an expanding population. Without immigrant physicians, Canada would have been unable to provide the number of doctors needed to make Medicare a success. By examining the statistics, the authors show that in the two-and-a-half decades after the passage of the 1957 Hospitalization Insurance and Diagnostic Services Act (HIDS Act) more than 15,000 foreign-trained doctors arrived in Canada. With this figure in mind, one of the authors’ goals is to observe the routes taken by international medical graduates as they migrated to and within the country.5 Because it concentrates mostly on Canada, Foreign Practices is also a national history as certain provinces and regions were affected by physician immigration more than others. According to Mullally and Wright, their text focuses, in particular, on the disparities that existed in the delivery of health services in “marginalized, rural, and remote communities,” the private or incorporated group practices, and the community health centres that were popular throughout these decades, as well as the growth of new Canadian medical schools. In analyzing these facets of health service delivery, the authors describe how immigrant physicians “fit into and exerted an influence on the economic and corporate structures” of Canadian health care. For example, as Mullally and Wright explain, the influx of foreign-trained doctors influenced the upper echelons of Canadian health care’s corporate structure as “a notable few of this generation of doctors” became “presidents of medical associations, heads of clinical departments, and deans of medical schools.” Yet, further down the corporate stratum, in rural or remote resource communities, “physicians’ health care practices” were restructured from “hierarchical to collaborative group practices” as a more democratic and equal working environment between physicians ensured higher rates of doctor retention in these difficult-to-service areas.6 Another contribution Mullally and Wright make is their analysis of the complex moral dilemmas surrounding the “brain drain,” which saw foreign-trained physicians leave developing nations in favour of opportunities in the developed world.7 And Mullally and Wright also present the problem of doctor [End Page 118] maldistribution that the Canadian federal and provincial governments tried to solve from time to time; this was done by forcing physicians to practise in...

Pass/fail decisions and standards: the impact of differential examiner stringency on OSCE outcomes

Variation in examiner stringency is a recognised problem in many standardised summative assessments of performance such as the OSCE. The stated strength of the OSCE is that such error might largely balance out over the exam as a whole. This study uses linear mixed models to estimate the impact of different factors (examiner, station, candidate and exam) on station-level total domain score and, separately, on a single global grade. The exam data is from 442 separate administrations of an 18 station OSCE for international medical graduates who want to work in the National Health Service in the UK. We find that variation due to examiner is approximately twice as large for domain scores as it is for grades (16% vs. 8%), with smaller residual variance in the former (67% vs. 76%). Combined estimates of exam-level (relative) reliability across all data are 0.75 and 0.69 for domains scores and grades respectively. The correlation between two separate estimates of stringency for individual examiners (one for grades and one for domain scores) is relatively high (r=0.76) implying that examiners are generally quite consistent in their stringency between these two assessments of performance. Cluster analysis indicates that examiners fall into two broad groups characterised as hawks or doves on both measures. At the exam level, correcting for examiner stringency produces systematically lower cut-scores under borderline regression standard setting than using the raw marks. In turn, such a correction would produce higher pass rates—although meaningful direct comparisons are challenging to make. As in other studies, this work shows that OSCEs and other standardised performance assessments are subject to substantial variation in examiner stringency, and require sufficient domain sampling to ensure quality of pass/fail decision-making is at least adequate. More, perhaps qualitative, work is needed to understand better how examiners might score similarly (or differently) between the awarding of station-level domain scores and global grades. The issue of the potential systematic bias of borderline regression evidenced for the first time here, with sources of error producing cut-scores higher than they should be, also needs more investigation.

The Important Factors Applicants Consider When Choosing a Residency: A Survey Study.

While medical school graduates compete to get matched into the best residency programs, programs also compete to attract the best applicants. The applicant's decision to rank their programs of interest is determined by several factors, many of which are not always apparent. This study aimed to evaluate significant factors involved in an applicant's residency program selection. A 12-question survey was sent between June 2020 and September 2020 to all first-year internal medicine residents in the United States (US) through an online national database of residencies using the Survey Monkey platform. We asked them to rank the most significant factors that enticed or deterred them from choosing a specific program. We also compared domestic with international medical graduate (IMG) average ranked responses wherein differences were evaluated using an independent two mean samples t-test. The association between outcomes and predictors was analyzed using Pearson's correlation and chi-square analysis. Out of 9,127 residents, 102 responded to the survey, which equaled a 1.11% response rate. The findings showed that the location, culture, and organization of a program are high-value factors for applicants. Salary, the number of cases seen, and friends near the residency location were not.There are statistically significant differences between graduates of US medical schools and IMG applicants, with the former placing higher importance on the quality of life during residency. Male and female residents also have different priorities with the latter emphasizing program culture and work environment improvement.Residents who chose programs based on academic competitiveness also placed significance on the prestige of the program (r = 0.418, P < .001), program organization/structure (r = 0.3, P = .006), fellowship match rate (r = 0.307, P = .006) and word of mouth (r = 0.520, P < .001). Residents who chose programs based on program culture also put an emphasis on the perceived happiness of the residents (r = 0.450, P = 0.001), and work-life balance (r = 0.359, P = .004). Programs can attract stronger applicants if they emphasize modifiable factors that are important to potential residents.

International medical graduate dermatologists in rural and medically underserved areas: a national cross-sectional analysis.

International medical graduates (IMGs) comprise a quarter of the United States (US) physician workforce but are a diminishing minority among dermatologists. Studies on IMGs in other specialties have demonstrated their importance in addressing provider shortage in rural and medically underserved areas (MUAs), but this trend has not been systematically explored within dermatology. This study aims to assess the state-by-state distribution of IMG dermatologists in the US as compared to US medical graduates (USMGs) with focus on provider density in rural settings and MUAs. A national cross-sectional study was performed on actively practicing dermatologists who submitted Medicare claims within 1year of July 2020; rural and MUA-serving status were determined based on federally designated rural-urban Continuum Codes and Census Bureau data. Nationally, the density of dermatologists has increased from 3.4 per 100,000 persons in 2016 to 3.66 per 100,000 persons in 2020. However, 70% of US states continue to have fewer than 4 dermatologists per 100,000 persons, the estimated minimum necessary to adequately care for a population. Among 12,009 dermatologists, only 576 (4.8%) are IMGs, with disparate distribution across the US: Kansas has the greatest percentage of IMGs with the latter comprising 8.3% of its state dermatology workforce, whereas 8 states have no IMGs. Notably, a significantly greater percentage of IMG dermatologists (43.9%) work in areas designated as MUAs compared to USMGs (37.4%) (P < 0.01). In contrast, a lower percentage of IMG dermatologists (2.8%) work in rural settings compared to USMGs (4.8%) (P = 0.03). Interestingly, no significant difference was observed when rural dermatologists were further stratified by MUA-serving status. These findings corroborate the importance of IMGs in providing greater access to dermatological care in areas with healthcare provider shortage. Further studies on the underlying causes of the decline of IMGs within dermatology are needed.

Yonder: International medical graduates, genetics at end-of-life, climate change, and paediatric antibiotic prescribing in China.

Yonder: International medical graduates, genetics at end-of-life, climate change, and paediatric antibiotic prescribing in China.

Recent trends in high-volume Medicare stroke thrombectomy provider characteristics

BackgroundIntracranial mechanical thrombectomy (MT) is increasingly indicated for use in acute ischemic stroke patients. We analyzed recent trends in the characteristics and geographic distributions of physicians providing this service with...

Broadening perspectives about incorporating international medical graduates.

The authors seek to help international medical graduates thrive by offering reflections on the perspectives of key stakeholders and discussions of IMGs' personal and professional experiences.

Becoming a neurosurgeon in the United Kingdom: A road map for medical students and early career doctors

Neurosurgery is one of the most sought-after specialties worldwide. It is one of the most competitive specialties in the United Kingdom. The entire process takes 8 years and the recruitment process aims to select the best of candidates. Not much has been said about the entire selection process from the online application to the interview process, especially with the unprecedented changes brought about by the coronavirus pandemic. There needed to be a roadmap of the entire process, from start to finish, to enable the medical students and early career doctors to make an informed decision, as well as prepare beforehand to meet the criteria that have been set out. A balanced perspective is needed as well, to highlight the drawbacks of pursuing this arduous training specialty in the United Kingdom. This article builds on existing information and throws more light on the application, interview, and the challenges faced by doctors in training. It also shows the challenges the international medical graduate might face during the application process in terms of the shortlisting matrix as well as during training. This article offers advice to all doctors willing to specialize in neurosurgery and highlights what they can do to improve their chances. It sheds more light on the interview process so that shortlisted doctors can know where to focus on during the interviews. Most importantly, by describing the challenges that may be encountered as doctors in training under the NHS, it aims to give a balanced view. This will enable the would-be candidate to make a well-informed choice.

International Medical Graduate Resident Wellness: Examining Qualitative Data From J-1 Visa Physician Recipients.

International medical graduates (IMGs), approximately 25% of the U.S. physician workforce, have unique needs as they enter residency programs. This study identified wellness barriers and challenges that IMGs encounter as they transition to the United States. The authors analyzed results from 3 open-ended questions in a 21-item survey. This survey was administered in December 2019 to 11,504 IMG resident physicians sponsored by the Educational Commission for Foreign Medical Graduates' J-1 visa program. These questions asked respondents to describe challenges to their wellness, how they maintain wellness, and resources that would have aided their transition. Data were analyzed using a mixed-methods approach, including both qualitative descriptions and category frequencies. Of the surveys administered, 7,817 responses (68% response rate) were received. Respondents identified challenges navigating cultural differences (1,314, 17%), health care system (1,108, 14%), distance from family and friends (890, 11%), bureaucratic barriers (724, 9%), and language/communication and finances (575, 7%; 565, 7%, respectively). They also specified that friendships/relationships (2,800, 36%) followed by exercise (2,318, 30%), family (1,822, 23%), socialization (1,001, 13%), and healthy eating (775, 10%) were factors important to their wellness. Respondents requested more information about socialization (741, 9%), bureaucratic support (456, 6%), IMG support networks (427, 5%), financial support (404, 5%), and greater online resources (240, 3%). IMGs have needs and concerns specific to their demographic group. Participants' responses suggested that they wanted additional support in the workplace and their personal lives. Answers also indicated that IMGs experienced a unique set of stressors such as fluctuating immigration laws that U.S. medical graduates do not face. Finally, this study supports a body of research that connects social and physical wellness. By identifying and describing these challenges, the authors seek to inform the development of specific programs and resources to improve IMG resident wellness.

Demographics, distribution and experiences of UK clinical academic trainees using GMC NTS Survey data.

Involvement in research plays an integral role in the delivery of high-quality patient care, benefitting doctors, patients and employers. It is important that access to clinical academic training opportunities are inclusive and equitable. To better understand the academic trainee population, distribution of academic posts and their reported experience of clinical training, we analysed 53 477 anonymous responses from General Medical Council databases and the 2019 National Training Survey. Academic trainees are more likely to be men, and the gender divide begins prior to graduation. There are very low numbers of international medical graduates and less than full-time academic trainees. A small number of UK universities produce a greater prevalence of doctors successfully appointed to academic posts; subsequent academic training also clusters around these institutions. At more senior levels, academic trainees are significantly more likely to be of white ethnicity, although among UK graduates, no ethnicity differences were seen. Foundation academic trainees report a poorer experience of some aspects of their clinical training placements, with high workloads reported by all academic trainees. Our work highlights important disparities in the demographics of the UK clinical academic trainee population and raises concerns that certain groups of doctors face barriers accessing and progressing in UK academic training pathways.

\u201cAt the mercy of some of the regulations\u201d: the impact of the residency match and return of service requirement on the early-career decisions of international medical graduates in Canada

BackgroundReturn-of-service (ROS) agreements require international medical graduates (IMGs) who accept medical residency positions in Canada to practice in specified geographic areas following completion of training. However, few studies have examined how ROS agreements influence career decisions. We examined IMG resident and early-career family physicians’ perceptions of the residency matching process, ROS requirements, and how these factors shaped their early career decisions.MethodsAs part of a larger project, we conducted semi-structured qualitative interviews with early-career family physicians and family medicine residents in British Columbia, Ontario and Nova Scotia. We asked participants about their actual or intended practice characteristics (e.g., payment model, practice location) and factors shaping actual or intended practice (e.g., personal/professional influences, training experiences, policy environments). Interviews were transcribed verbatim and a thematic analysis approach was employed to identify recurring patterns and themes.ResultsFor this study, we examined interview data from nine residents and 15 early-career physicians with ROS agreements. We identified three themes: IMGs strategically chose family medicine to increase the likelihood of obtaining a residency position; ROS agreements limited career choices; and ROS agreements delayed preferred practice choice (e.g., scope of practice and location) of an IMGs’ early-career practice.ConclusionsThe obligatory nature of ROS agreements influences IMG early-career choices, as they necessitate strategically tailoring practice intentions towards available residency positions. Existing analyses of IMGs’ early-career practice choices neglect to distinguish between ROS and practice choices made independently of ROS requirements. Further research is needed to understand how ROS influences longer term practice patterns of IMGs in Canada.

Foreign-Trained Physicians in the United States: A Descriptive Profile.

More than a quarter of physicians in the United States are international medical graduates (IMGs). This statistic, although large, does not fully capture the importance of IMGs in certain specialties and locations. We provide a comprehensive profile of IMGs documenting where and in what specialties they work and how these distributions have changed over time. Estimates show that IMGs disproportionately work in densely populated, low-income communities with sicker residents and low physician density. IMGs are overrepresented in primary care and the lowest paying specialties, and their concentration in these specialties is growing. Calculations show that U.S. medical graduates exit the workforce at 2.5 times the exit rate of IMGs suggesting that in the near future IMGs will likely provide care for an increasingly larger share of Americans.

To the Editor: Holistic Approach to Resident Selection May Eliminate Potential Biases Associated With USMLE Step 1 Pass/Fail Scoring System.

We read with profound interest the article by Ganesh Kumar et al1 highlighting trainee perspectives regarding the use of a United States Medical Licensing Examination (USMLE) pass/fail score in place of the traditional 3-digit numerical scoring system for resident selection in graduate medical education (GME) residency programs. The authors surveyed a diverse cohort of residents, fellows, and medical students, inclusive of US allopathic (MD) students, US osteopathic (DO) students, and international medical graduates (IMGs) in 2020. A total of 11 633 trainees (7254 residents/fellows and 4379 medical students), 14% of which were underrepresented in medicine (UiM), responded to the survey and provided insights on this controversial subject. The authors emphasized in their discussion that, although 35% of the respondents supported the proposed USMLE Step 1 pass/fail scoring system, 44% of the survey respondents disliked this system. US allopathic medical students and UiM trainees were the most supportive of a USMLE Step 1 pass/fail scoring system. In contrast, many non-UiM, DO, and IMG respondents felt that they would be at a disadvantage. Regarding the secondary outcome measure that a USMLE Step 1 pass/fail scoring system will reduce socioeconomic disparities in resident selection, it was fascinating to read that UiM medical students primarily supported this hypothesis. We applaud the Vanderbilt University investigators for performing this study, which provides GME leaders with vital data as we transition to a USMLE Step 1 pass/fail scoring system.In the United States, GME is at a crucial crossroads regarding resident selection. Historically, USMLE Step 1 scores have served as a benchmark for screening resident candidates, especially in highly competitive programs. Although USMLE scores may reflect some degree of inherent knowledge, the preparation required to excel on the examination may also depend on socioeconomic factors. Medical students often take multiple preparation courses, such as the PASS Program and Kaplan, to improve their content knowledge and test-taking skills for the USMLE examinations. Many of these are high cost, and in an era of rising medical school tuition costs, access may be limited to students with adequate financial resources. Students from socioeconomically disadvantaged backgrounds may have lower USMLE Step 1 scores because of reduced resources. For this and other reasons, the decision to move to a USMLE Step 1 pass/fail scoring system was made. However, as found by Ganesh Kumar et al,1 trainees who responded to this survey had varied perspectives—a significant subset of these respondents, particularly DO and IMG trainees, were skeptical of this transformation. As a result, we caution GME leaders to be thoughtful with this new binary USMLE Step 1 pass/fail scoring system, because it may introduce additional implicit biases against DO and IMG applicants. It may be helpful to remove credentials that could encourage implicit bias, such as the MD, DO, or IMG designation when reviewing an applicant.The critical question now becomes: How will residency admission committees identify top-level applicants in the era of a USMLE Step 1 pass/fail scoring system? We believe that using a meritocratic, holistic approach to residency admission, inclusive of letters of recommendation, the binary USMLE Step 1 pass/fail score, medical school transcripts, trainee experiences, personal attributes, interview performance, and barriers encountered during their education and training, can identify the best and brightest medical students for residency programs.2 Hopefully, this holistic approach to resident selection will eliminate ingrained socioeconomic disparities that may hinder UiM students from joining competitive residency programs.

The AOA/ACGME Single Accreditation System and Its Immediate and Future Impact on Family Medicine.

The American Osteopathic Association (AOA) agreed to combine its graduate medical education programs with the Accreditation Council for Graduate Medical Education (ACGME) between July 1, 2015 and June 30, 2020 in an initiative called the Single Accreditation System (SAS). The objective of our study was to identify the impact the SAS had on the ACGME, family medicine (FM), and implications for the future of FM. We collected and compiled data from the AOA, ACGME, and the National Residency Matching Program (NRMP). Analysis reveals the effects that the addition of former 122 AOA-accredited FM residencies had on the ACGME and FM programs. Several osteopathic FM programs encountered challenges meeting ACGME accreditation standards. As of June 1, 2020, 89 of 122 accreditation applications received initial or continuing accreditation; the others had accreditation issues to resolve. The Osteopathic Recognition program emphasizing training in osteopathic principles and practices was a popular option in FM residencies. Fewer DOs serve as program directors in former AOA-accredited FM residencies. The SAS has shifted the balance in the percentages of MDs, DOs, and international medical graduates (IMGs) in FM. Trends in FM show that as more DOs enter the NRMP the percent of MDs and IMGs decreases. In the future, it is projected that DOs will outnumber MDs and IMGs in ACGME FM residencies. The 51 new medical schools started between 2010 and 2020 will generate a test for the integration of their graduates into GME. Increased competition for FM residencies is expected.

COMLEX-USA and USMLE for Osteopathic Medical Students: Should We Duplicate, Divide, or Unify?

COMLEX-USA and USMLE for Osteopathic Medical Students: Should We Duplicate, Divide, or Unify?

Disaggregating inequalities in the career outcomes of international medical graduates in the United States.

Although research finds that international medical graduates (IMGs) fill gaps in US health care left by US medical graduates (USMGs), the extent to which IMGs' career outcomes are stratified along the lines of their country of medical education remains understudied. Using data from the 2019 American Medical Association Physician Masterfile (n=19,985), I find IMGs from developed countries chart less marginalised paths in their US careers relative to IMGs from developing countries; they are more likely to practise in more competitive and popular medical specialities; to attend prestigious residency programmes; and to practise in less disadvantaged counties that employ more USMGs relative to IMGs. These findings suggest IMGs experience divergent outcomes in the United States based on their place of medical education, with IMGs from developing countries experiencing more constraints in their careers relative to IMGs from developed countries. This understudied axis of stratification in medicine has important implications for our understanding of how nativism and racism may intersect to generate inequalities in the medical profession and in US health care more broadly.

Burnout: exploring the differences between U.S. and international medical graduates

BackgroundInternational medical graduates (IMGs) have less burnout than U. S. medical school graduates (USMGs) during residency training. This study evaluates possible correlates of differences in burnout rates between USMGs and IMGs.MethodsWe surveyed 375 first-year residents at orientation in June/July 2017. We assessed burnout using the Copenhagen Burnout Inventory (CBI) and used validated scales to measure stress, quality of life (QoL), mastery, and spirituality. We collected data on gender, place of graduation, language fluency, and specialty. We compared CBI scores between USMGs and IMGs, performed a multivariate linear regression analysis of relationships between covariates and CBI subscales, and logistic regression analysis for our categorical definition of burnout.ResultsTwo hundred twenty-two residents responded for a response rate of 59%. Personal, work or patient- related burnout was common among residents, particularly among USMGs. The most common form of burnout was work-related. Forty nine percent of USMGs have work burnout compared to 26% of IMGs (p < 0.01). In multivariate analysis, being an IMG reduced odds of work-related and of total burnout by 50% (OR 0.5 C.I 0.25-0.99). Perceived mastery was associated with reductions in all subscales of burnout (p < 0.05). Stress and low QoL related to personal and work burnout scores (p < 0.01).ConclusionWork-related burnout is more common among USMGs than in IMGs. Although mastery, QoL and stress were correlates of burnout among all residents, these factors did not explain the difference. Future studies should evaluate the role of medical school structure and curriculum on differences in burnout rates between the two groups.

Training, performance and value of Latinas in the United States urology workforce

With the increasing diversity in the population of the United States, efforts and interest in diversity in healthcare have followed. The article offers an insightful review of recent studies evaluating the role of women and underrepresented minorities (URM) in Urology in order to better understand the state of Latinas in Urology. We review the representation of women in urology residency in the United State (U.S.), international medical graduates (IMGs) in urology, and the most recent initiatives developed by urologists to increase diversity in the urological community to better reflect the communities served.