To the Editor.
—The 12-avenue approach of Starfield and Simpson1 to upgrade primary care in US health services is innovative. Maldistribution of physicians still leads to a significant shortage of primary care physicians across the United States.The role of international medical graduates (IMGs) needs to be emphasized. Their numbers are almost equivalent to the the graduate output of approximately 17 US medical schools, with as many as 58% of these IMGs in 1988 alone being non-US citizens.2 The bulk of them enter the United States on the exchange visitor's (J-1) program and receive their training at the expense of the United States for periods ranging from 3 to 5 years. They return to their home countries where they often find that their acquired expertise is inappropriate owing to lack of facilities and resources. Hence, the magnanimity of the United States and the well-intended purpose of the J-1
Vasireddi SS. Primary Care as Part of US Health Services Reform. JAMA. 1993;270(20):2434. doi:10.1001/jama.1993.03510200038019