Author: Sajeet Sohi, M.D.
Traditionally, discussions regarding the physician shortage and primary care gap have focused on the attitudes, career decisions, and supply of U.S. medical students.1-2 An alternative approach is to increase the International Medical Graduate supply stream. The IMG community now represents 25% of practicing physicians, are more likely to become primary care physicians and practice in a rural area.3-5 There is no significant difference in patient mortality between those patients who were treated by IMGs compared to all U.S. graduates.6 Optimizing the IMG physician supply chain should be considered an integral part of the solution. A two pronged approach involves a standardized basic sciences curriculum and utilizing new organizations introduced in healthcare reform to increase the physician supply.
Obstacles Remain For International Medical Graduates
There are challenges facing the IMG community including: obtaining appropriate work visas, the ethical implications of these individuals leaving their homeland, integration into the American healthcare system and culture, and possible or perceived discrimination in the residency selection process.7-9
Completing the USMLE series of examinations is a difficulty for IMGs and this may be due to language comprehension, inadequate medical school education, or problems with standardized testing.10-13
|USMLE Step 1||USMLE Step 2 CK||USMLE Step 2 CS|
|US Citizens (IMG)||55%||69%||79%|
|Foreign Citizens (IMG)||67%||80%||68%|
|US/Canadian Medical Students||91%||96%||97%|
Table 1: USMLE Pass Rates for IMG,U.S., and Canadian Medical Students.
Source: ECFMG 2009 Annual Report14 and NBME 2009 Annual Report15
The USMLE pass rates may be seen as a validation that certain students of “Offshore Medical Schools” are individuals who may not have the capacity or competence to be a quality care provider. An alternative viewpoint is that we have a population of individuals who have hit a roadblock due to a non-standardized medical school curriculum or medical education not tailored to the USMLE content. It has been noted recently that using USMLE Step 1 and Step 2 scores as a method for resident selection is neither structured, coherent, or evidence based.16
Proposal #1: Standardized Basic Sciences Medical School Education
To create an enhanced supply of physicians the medical educational process must offer medical students a fair playing field to succeed. The establishment of a standardized basic sciences curriculum instituted from the NBME, ECFMG, or a new organization would allow uniform preparation across the spectrum of applicants. This group would be responsible for creating a series of guidelines, textbooks, and electronic media with the expected relevant information that would be presented in the USMLE examinations. This would not be intended to replace a school’s curriculum, rather to highlight what will be expected on the examinations. With the proliferation of information technology the content could be delivered through an online-open source forum. Over time we would see which type of teaching methods offer the best outcomes. The project would be funded by a one time fee from each student in a licensed LCME or ECFMG associated institution interested in U.S. graduate medical education.
Proposal #2: The Center for Medicare and Medicaid Innovation, Accountable Care Organizations, and Healthcare Innovation Zones as a Method to Increase GME Positions
The rate-limiting step to produce physicians remains the number of residency positions. In fact, in the 2010 residency matching process there were only 0.75 residency positions per applicant (according to the NRMP), thus 25% of applicants are automatically denied training positions.
|Year||U.S. Senior||U.S. IMG||Non- U.S. IMG||Others||All Applicants|
Table 3: PGY1 Match Rates. Source: NRMP Results and Data 2010 Main Residency Match17
The underlying theme of healthcare reform is to deliver care in an efficient and effective method. The Centers for Medicare and Medicaid Innovation (CMMI) plans for a dialogue which aims for better care for individuals, coordinating care to improve healthcare outcomes for individuals, and community care models.18 Accountable Care Organizations (ACO) aim to improve the quality of care and reduce unnecessary costs to Medicare beneficiaries.19 Healthcare Innovation Zones (HIZ) will help redesign academic medical centers to focus on healthcare delivery, medical education, and research.20 Together the CMMI, ACO, and HIZ have the potential to pool resources and increase GME positions.
The U.S. medical school supply is running at maximum capacity and efficiency; thus, international medical graduates are uniquely suited to be integral players in the solution. International medical graduates are more likely to become primary care providers and can begin to address the lack of primary care providers in the American health care system. However, these students can only fill this gap if there is a standardized medical school education and increased graduate medical educational positions with the leadership of the CMMI, ACO, and HIZ. Although these proposals may lack specific details and be seen as the idealistic thoughts of a young physician in training, we can use this opportunity to explore new avenues to produce the next generation of physicians.
About The Author: Sajeet Sohi, M.D. is a recent International Medical Graduate
Medical School: Aureus University School of Medicine, Aruba (2011)
Undergraduate: University of Toronto, Hons. BSc. (2007)
Conflicts of Interest/Disclosures: None
Keywords: USMLE, international medical graduate, graduate medical education, primary care provider, physician shortage, residency
About the Author: firstname.lastname@example.org