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April 5, 2000

Continuing Controversy Over the International Medical Graduate

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JAMA. 2000;283(13):1746. doi:10.1001/jama.283.13.1746-JMS0405-2-1

Over the past 5 years, more than 20,000 graduates of foreign medical schools have entered residency programs in the United States to obtain graduate medical education. The vast majority of these international medical graduates (IMGs) have gone on to practice in the United States after completing their training. Consequently, the number of IMGs has risen steadily reaching nearly 25% of all allopathic physicians practicing in the United States.1

Considerable controversy surrounds this influx of physicians from abroad at a time when the US health care system is undergoing dramatic change. Concern over a potential physician surplus has caused several prominent policy groups to call for a cap on the numbers of foreign national IMGs permitted to remain permanently in the United States.2 With growing pressure to curb Medicare reimbursements to teaching hospitals, policy analysts have also questioned the allocation of funds for graduate medical education to pay for residency positions for IMGs.3

Supporters of the open-door policy toward IMGs have countered that these physicians practice in disproportionately high numbers in areas of the country that have been neglected by the US health care system. For some time, workforce experts have debated whether such IMGs provide a national service by alleviating the geographic maldistribution of physicians throughout the country.4 Others ask why the United States, with its overall wealth and burgeoning medical education system, is not able to provide care in so many of its communities using physicians trained in its own medical schools

At the same time, the widespread perception that IMGs receive inferior training in foreign medical schools continues to dog IMGs' efforts to prove that they provide quality care to these communities.5 The creation of the new Clinical Skills Assessment (CSA) exam as a requirement for IMGs seeking entry into a US residency program is evidence of concern that IMGs do not have adequate clinical and interpersonal skills to care for US patients.

This issue of MSJAMA explores some of the questions raised by IMGs' controversial presence in the United States. How have recent immigration restrictions on foreign national physicians changed the composition of the US physician workforce? To what extent do IMGs provide care to segments of the population that have traditionally been neglected by US medical graduates? What sort of cultural barriers must IMGs overcome in order to deliver care to patients in the United States? What role do clinical-based exams such as the CSA play in standardizing the quality of care provided by all graduates entering residency training?

Pasko  TSwidman  B Physician Characteristics and Distribution in the US, 1999 Edition.  Chicago, Ill American Medical Association1999;
Council on Graduate Medical Education, Eleventh Report: International Medical Graduates, the Physician Workforce and GME Payment Reform.  Rockville, Md US Dept of Health and Human Services1998;
The Medicare Payment Advisory Commission, Report to Congress: Medicare Payment Policy.  Washington, DC Medicare Payment Advisory Commission1998;
Mick  SSLee  SD The safety-net role of international medical graduates. Health Aff (Millwood). 1999;16141- 150Article
Mick  SSComfort  ME The quality of care of international medical graduates: how does it compare to that of US medical graduates? Med Care Res Rev. 1997;54379- 413Article