US Medical Graduates Research Articles

Integrating geriatrics into the subspecialties of internal medicine: the Hartford Foundation/American Geriatrics Society/Wake Forest University Bowman Gray School of Medicine Initiative.

Integrating geriatrics into the subspecialties of internal medicine: the Hartford Foundation/American Geriatrics Society/Wake Forest University Bowman Gray School of Medicine Initiative.

The changing supply of renal physicians

In 1993, there were 4,355 active, postresident physicians in the United States who, according to the American Medical Association (AMA) Physician Masterfile, had their primary specialty in either adult nephrology or pediatric nephrology. These renal physicians constituted 0.8% of the active postresident physician population, and there were 1.67 renal physicians for every 100,000 people in the United States. The population of renal physicians has grown at a significantly greater rate than the physician population as a whole. The number of renal physicians increased more than 10-fold between 1970 and 1993, and it increased by 19% between 1990 and 1993. In recent years, the growth of the renal physician population has been bolstered by the large number of new international medical graduates (IMGs) entering the United States, who have entered nephrology at a much higher rate than entering US medical graduates (USMGs). The future growth of the renal physician population will be determined by a wide variety of factors, including future trends in specialty selection and whether policies are implemented to reshape the physician workforce. The projection analysis of the future supply of adult nephrologists considers three different scenarios. First, if the production of new nephrologists remains at status quo, the supply of adult nephrologists will increase 101% between 1993 and 2010. However, it is possible that the number of entrants into the adult nephrologist population will increase because of the large influx of IMGs in US residency programs in recent years. If new IMGs continue to enter adult nephrology at their current rates and if this heightened level of entry is sustained, the supply of adult nephrologists will increase 134% between 1993 and 2010. Finally, if proposals are implemented to reduce the number of first-year residency positions to 110% of the number of new graduates of US medical schools and to raise the proportion of new physicians entering primary care to 50%, the supply of adult nephrologists will increase 62% between 1993 and 2010. The demand for nephrologists' services is likely to grow in the near future. The prevalence rate of end-stage renal disease (ESRD) more than doubled between 1984 and 1993, and a continuation of this trend will expand the need for more nephrologists. The long-term growth of the ESRD population will also be sustained, to some extent, by the aging of the US population, because the prevalence of ESRD is relatively high in the older age categories. However, long-term increases in the demand for nephrologists may be restricted by the growth of managed care, the use of nonphysician providers, and the implementation of other cost-cutting measures that impact the delivery of services to the ESRD population.

Domestic Production vs International Immigration

To determine alternate combinations for reductions in US medical school graduates (USMGs), international medical graduate (IMG) immigration, and graduate medical education (GME) residencies, based on future physician supply targets. A demographic projection model of the physician supply was constructed and calibrated to fit observed American Medical Association Physician Masterfile data and current supply forecasts. Total annual input to GME was backcast from given future supply targets, adjusting for the portion of IMGs in GME who do not enter the US workforce. The annual number of new physicians added to supply from domestic or international sources needed to reach future physician-to-population ratio targets. Because of the low rate of attrition from the physician supply, it takes up to 50 years for workforce policy to effectively stabilize the physician-to-population ratio at a target level. All target ratios considered here would require immediate reductions in the total number of GME positions. These reductions must be followed by gradual annual increases to account for population growth. The size of USMG and IMG reductions are interrelated and depend critically on the percentage of IMG trainees who remain to practice in the United States. Reductions in future physician supply can come from either the IMG or USMG component of physician production, or both. The model developed here allows the estimation of multiple combinations of both GME components.

Comparison of IMG-Dependent and Non—IMG-Dependent Residencies in the National Resident Matching Program

To provide insight into the dynamics that determine the pattern of participation of international medical graduates (IMGs) in graduate medical education (GME). Data on IMG-dependent programs (ie., those having at least 50% of first-year positions filled by IMGs) and non-IMG-dependent programs in 6 core specialties (internal medicine, family practice, obstetrics and gynecology, surgery, pediatrics, and psychiatry) were matched with application data from the 1989 and 1995 National Resident Matching Program (NRMP). Participation of IMG-dependent and non-IMG-dependent programs in the 1995 NRMP and the pattern of US medical graduate (USMG) and IMG applications to these programs in 1989 and 1995. Of the 1634 programs in the 6 specialties, 93.5% participated in the 1995 NRMP. The 1165 non-IMG-dependent programs were significantly more likely to participate in the NRMP and were slightly more likely to fill their offered positions than were the 469 IMG-dependent programs. Specifically, IMGs constituted 76% of applicants to IMG-dependent programs and only 14% of applicants to non-IMG-dependent programs. Changes in NRMP data between 1989 and 1995 indicated that the number of IMG applications to IMG-dependent programs increased 88.7%, as did the number of applicants ranked. Persistent differences exist in the mix of USMGs and IMGs applying through the NRMP to IMG-dependent and non-IMG-dependent programs. Over time, programs that enroll large numbers of IMGs are likely to experience an increase in the number and proportion of applications from IMGs and a decrease in the number and proportion of applications from USMGs. If policies are adopted to limit IMG access to GME, IMG-dependent programs may be unable to recruit USMGs unless the total number of GME programs or the quality of existing programs fundamentally changes.

The Shifting Sands of Graduate Medical Education

Each year the American Medical Association (AMA) surveys all programs in graduate medical education (GME) accredited by the Accreditation Council for Graduate Medical Education. Because of the importance of GME in the national workforce policy debate, this year's survey report has been expanded to provide more detailed GME data. The authors describe the historical basis of the current GME workforce dilemma and the multiple forces that now tend to neutralize efforts to adapt to a changing marketplace. For example, as resident physicians find it increasingly difficult to locate suitable employment, one would expect a reduction in hospital-based programs and in the number of their resident physician appointments. Yet, while US medical graduates (USMGs) did not pursue certain programs in this year's National Resident Matching Program, AMA data show that during the past 2 years the reduced number of residents in hospital-based programs was almost exactly offset by the increased number in new and expanded programs. Also, more USMGs are leaving residency training to enter practice after 3 years of basic training in primary care (internal medicine, pediatrics, and family practice). At the same time, an increasing number of international medical graduates are remaining in subspecialty programs. Other examples are cited to show the ebb and flow of GME activities that behave like "shifting sands."

International Medical Graduates in Rural America: The 1987 Distribution of Physicians Who Entered the U.S. Medical System Between 1969 and 1982

This study examines the differential location on Dec. 31, 1987, in nonmetropolitan U.S. counties of a cohort of international medical graduates (IMGs) (n = 246,754) certified by the Educational Commission for Foreign Medical Graduates between 1969 and 1982, and a matched group of U.S. medical graduates (USMGs). Analysis of counties grouped into categories of population size revealed disparities across certain U.S. census divisions. IMGs were distributed disproportionately in the West North Central and East South Central census divisions. The implications of the IMG presence in numerous rural counties is discussed from the perspective of recent policy proposals to reduce the number of IMGs in the United States.

Medical migration and the physician workforce. International medical graduates and American medicine

<h3>Objective.</h3> —Because of the size and growth of the international medical graduate (IMG) contribution to graduate medical education (GME) in the United States, and subsequently to the US physician workforce, it is essential to understand the demographics and patterns of IMG training and practice as well as the routes of entry into the United States. <h3>Data Sources.</h3> —Published data from the American Medical Association, the American Osteopathic Association, and the Association of American Medical Colleges; tabular runs of county-level data contained on the Bureau of Health Professions' Area Resource File. <h3>Results.</h3> —The majority of IMGs who participate in GME in the United States ultimately enter US practices. 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 GME training as an international educational exchange program. International medical graduates gravitate toward initial residency programs in internal medicine and pediatrics, many of which have unfilled positions; however, IMGs subspecialize at a disproportionately high rate, reducing their net contribution to the generalist pool. Patterns of ultimate practice location of IMGs parallel the patterns of US medical graduates (USMGs). <h3>Conclusions.</h3> —In recent years, participation of IMGs in GME and practice has increased significantly. Most IMGs in GME are not exchange visitors, but are either permanent residents or US citizens. Patterns of specialization and location of IMGs ultimately mirror those of USMGs. National IMG policy must be examined in light of the projected surplus of physicians in the United States. The best option for long-term control of the number of physicians in practice, USMG or IMG, is a system of specifying the number of GME positions nationally. (<i>JAMA</i>. 1995;273:1521-1527)

Medical migration and the physician workforce. International medical graduates and American medicine.

Because of the size and growth of the international medical graduate (IMG) contribution to graduate medical education (GME) in the United States, and subsequently to the US physician workforce, it is essential to understand the demographics and patterns of IMG training and practice as well as the routes of entry into the United States. Published data from the American Medical Association, the American Osteopathic Association, and the Association of American Medical Colleges; tabular runs of county-level data contained on the Bureau of Health Professions' Area Resource File. The majority of IMGs who participate in GME in the United States ultimately enter US practices. 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 GME training as an international educational exchange program. International medical graduates gravitate toward initial residency programs in internal medicine and pediatrics, many of which have unfilled positions; however, IMGs subspecialize at a disproportionately high rate, reducing their net contribution to the generalist pool. Patterns of ultimate practice location of IMGs parallel the patterns of US medical graduates (USMGs). In recent years, participation of IMGs in GME and practice has increased significantly. Most IMGs in GME are not exchange visitors, but are either permanent residents or US citizens. Patterns of specialization and location of IMGs ultimately mirror those of USMGs. National IMG policy must be examined in light of the projected surplus of physicians in the United States. The best option for long-term control of the number of physicians in practice, USMG or IMG, is a system of specifying the number of GME positions nationally.

Training Physicians: The Case of Internal Medicine

On Black Tuesday in 1987, many prestigious internal medicine residency programs failed to fill for the first time ever with US medical school graduates. This led to an intensive examination of residency training by chairpersons, deans, and others. As part of this effort, the authors launched an analysis, summarized in Training Physicians , to try to understand the reasons for the lack of popularity of what had been regarded (at least by internists) as the premier residency. The book draws from three diverse sources: a 17-year survey of internal medicine residency programs carried out by the University of Chicago Center for Health Administration Studies, interviews with 55 prominent internists, and a literature survey. Over the six years in which it was prepared, the authors developed larger objectives, and they attempt to use the material they gathered on internal medicine residency training to formulate insights into what has gone wrong with American

How Will Graduate Medical Education Reform Affect Specialties and Geographic Areas?

To project specialty and geographic impacts of workforce reform proposals on the practice output of graduate medical education (GME). A demographic life-table model to predict GME output was developed using 1987 cohort data from the Association of American Medical Colleges Annual GME Census. The 1992 GME cohort was used as a baseline to compare the simulated impact of alternate specialty and regional policies. Allopathic and osteopathic GME programs in the United States. Projected number of physicians (MDs and DOs) entering nine categories of practice specialty at the conclusion of GME. If GME input is reduced to 110% of US medical graduates with 55% entering practice as generalists (including obstetrics and gynecology), then the total number of first-year positions will decline from 24,433 to 18,783, and the total number of residents in GME would decline from 103,858 to 80,699 at equilibrium. Even with a 110% restriction on GME input, the overall physician-to-population ratio will continue to grow, albeit at a much slower rate. The number of generalists leaving GME annually would increase by 742 (9%) and the number of specialists would decline by 6517 (44%). At the regional level, allocating GME positions by prorating to the current distribution results in less change than would prorating positions to regional populations. Achieving national goals of reduced aggregate physician production, reduced specialist supply, and generalist increases will require significant alterations in the GME pool. Adequate time and funding for resident substitution will be required for hospitals to develop alternate models of providing service to allow national workforce goals to be met.

Counting Generalist Physicians

THERE HAS recently been renewed interest in the specialty balance in the US physician workforce, with many groups calling for increased production of generalist physicians. A number of factors are responsible for this, including declining medical student interest in generalist careers, 1 continued shortages in rural and inner-city areas, 2,3 increased demand from managed care organizations, cross-national experience, 4 as well as some evidence of cost savings from higher proportions of generalists. 5,6 The Council on Graduate Medical Education 7 has called for a reduction in first-year graduate medical education positions to 110% of US medical graduates with a 50:50 generalist-to-specialist mix, and the Physician Payment Review Commission 8 has also considered such changes. Similar recommendations have been proposed in the Clinton Health Security Act as well as independently in Congress. Such changes are significant and could be approached from a variety of educational, financial, and regulatory perspectives. In order

The Ides of March

The total number of US medical school graduates who selected categorical programs in internal medicine in this year's match fell by 7.9%. Consequently, the program fill rate for US graduates declined for the eighth consecutive year, from 55.9% to 53.1%. Preliminary positions and international graduates continue to increase, though questions remain whether these residents serve as good role models to encourage student interest in internal medicine. We reviewed the 1993 National Resident Matching Program data and several curricular reforms implemented in our internal medicine clerkship and residency program to evaluate whether such reform might enhance interest in general internal medicine. Reform in our internal medicine clerkship curriculum included increased emphasis on problem-based learning and exposure to generalist role models. This resulted in substantial increases on the average miniboard examination and a 22% increase in the number of students pursuing residency in internal medicine from the previous year. Residency curricular reform centered around enhanced ambulatory care teaching along with improved exposure to generalist role models. This resulted in a gradual increase in the number of residency graduates who were staying in general internal medicine from 21% in 1991 to 40% in 1993. Innovative curricular changes in our internal medicine clerkship and residency programs have led to enhanced interest in general internal medicine. Although our results are preliminary, such change is necessary, not only to continue program excellence, but for simple survival.

The Perspectives of Current Trainees in Combined Internal Medicine—Pediatrics

To gather information from combined internal medicine-pediatric residents about their application process for residency, their perceptions of the stressors during residency, and their future plans. Survey of all combined internal medicine-pediatric residents-in-training in the 1989-1990 academic year. Fifty-four percent of residents-in-training responded to the survey, representing 70% of the programs. Combined residents often investigate and rank other generalist residences. However, internal medicine is significantly (P < .005) considered more often than pediatrics or family medicine. Sixty percent of combined residents do not anticipate further training beyond the 4 years and expect to practice both specialties. The majority of those interested in a subspecialty expect to continue to combine internal medicine and pediatrics in their subspecialty practice. Switching services during the residency engenders stress. Factors that decrease stress include more frequent switches and increasing seniority. Switching from pediatrics to internal medicine is more stressful (P < .0001) than switching to pediatrics from internal medicine. The residents considered ambulatory training sites and a specific coordinator for the program to be the most important features of the residency. Combined internal medicine-pediatric programs continue to attract a small cohort of well-qualified US medical school graduates, the majority of whom intend to practice as generalists in both pediatrics and internal medicine.

Promoting Primary Care: Where to Start?

To the Editor. —The article by Stimmel 1 underscores our present and potentially worsening crisis in supply of US medical school graduates choosing to be primary care physicians. As pointed out last year in an article that dealt with specialty mix and health status, a primary care system is the foundation of health care in other nations of the developed world. 2 Our subspecialty-dominant system is top-heavy, with a poor primary care base. Stimmel mentioned some of the causes of the shrinking primary care residency applicant pool—perceived poorer monetary, prestige, and life-style rewards. These same factors have been well-documented in other forums, 3,4 as roots of discontent with primary care are explored. A major difference between the recent article by Stimmel and prior articles is that he included one important component of the solution—strengthening the National Health Service Corps (NHSC). I firmly believe that curricular, life-style, and back-end monetary redresses

The effect of federal grants on medical schools' production of primary care physicians.

Title VII of the Health Professions Educational Assistance Act of 1976 was created to encourage the production of primary care physicians. This study explored recent trends in the proportion of US medical school graduates entering primary care in relationship to Title VII funding. The American Medical Association Physician Masterfile was used to determine the specialty choice of all students graduating from American medical schools between 1960 and 1985. The proportion of graduates entering primary care rose from 19.7% in 1967 to 31.1% in 1976 and remained stable for the subsequent decade. The increase occurred before implementation of Title VII. Rural, state-owned medical schools with departments of family medicine tend to produce a greater proportion of primary care physicians than urban private schools without family medicine departments. The values of American medical schools and the reward structure of American medical practice favor the production of specialists over primary care physicians. Although Title VII helped to encourage and sustain the development of primary care educational programs at both the medical student and graduate levels, an increase in the proportion of primary care physicians will require fundamental changes.

Report of the Medical Schools Section Primary Care Task Force

THE percentage of physicians practicing a primary care specialty has declined, from about one half of total physicians in 1963 to about one third in 1986. One reason for this change is the retirement of general practitioners from medical practice. 1 These physicians are not being replaced at the same level, due to the decreased interest in primary care displayed by more recent US medical school graduates. 2 For example, results from the 1992 National Residency Matching Program showed that about 62% of the available positions in family practice, 64% of the positions in pediatrics, and 60% of the positions in internal medicine were filled with US seniors (memorandum from Norman Kahn, Jr, MD, American Academy of Family Physicians, to Commission on Education, March 17, 1992). In addition, 60% of the individuals initially entering residencies in internal medicine and 40% of those in pediatrics later pursue subspecialty training (Lyttle et

Licensing of International Medical Graduates

To the Editor. —The otherwise informative article on licensure of international medical graduates (IMGs) concluded that conversation with US medical graduates regarding licensing boards might lead IMGs to believe that they are not treated much differently after all. 1 However, the article misses the main point of contention. The licensing boards have introduced protectionist policies using the excuse of necessity for protecting the public from suboptimally trained IMGs. The discrimination is extended not only to those who are truly suboptimally trained but also to those who have better training than the average US medical graduate. For instance, board-certified ophthalmologists from Great Britain or South Africa had, by the time of their board-equivalent examinations, undergone more rigorous (and longer) training than their US counterparts. Regardless whether one considers the respective ophthalmology residencies equivalent, in no way can any licensing board justify the discrimination that follows the arrival of such an ophthalmologist in

The national resident matching program

To the Editor. —The continued decrease in the number of US medical school graduates selecting a career in internal medicine 1,2 will exert a negative effect on the status and future of ( continued on p 225. ) ( continued from p 221. ) the specialty should this trend not be reversed. 3 This decline in interested applicants has led to malaise among internists. Signs of malcontentment perceived through the eyes of medical students will only cause those eyes to look elsewhere. Rather than reminisce about the joys of bygone days when internal medicine was the queen of specialties, we must take steps to remedy the trouble at hand. Problems of litigation, third-party payments, and the acquired immunodeficiency syndrome epidemic are not unique to internal medicine, and must be addressed by all physicians. For internal medicine, the heart of the problem lies in the perceived stature and contribution of the internist. From a student

Trends in evolution of specialty choice. Comparison of US medical school graduates in 1983 and 1987

Trends in evolution of specialty choice. Comparison of US medical school graduates in 1983 and 1987

Personal Characteristics, Career Plans, and Specialty Choices of Medical Students Elected to Alpha Omega Alpha

Among US medical graduates in 1983, personal characteristics, career plans, and specialty choices of men and women elected to Alpha Omega Alpha (AOA), the honor medical society, differed in a number of ways from those of their non-AOA classmates. Students in AOA scored significantly higher on each subtest of the Medical College Admission Test, were disproportionately white, and had a higher proportion of parents achieving a post-high school education. Members of AOA participated in undergraduate medical research and authored papers during medical school significantly more frequently than those who were not members of AOA, planned a major career commitment to research, and planned careers in academic medicine significantly more frequently than those who did not belong to AOA. In contrast, neither religious preference, among students from Catholic, Jewish, or Protestant backgrounds, nor gender differentiated members of AOA from non-AOA members. Among the 15 specialties studied, internal medicine subspecialties and internal medicine attracted the highest proportion of students elected to AOA.