A recently released position paper from the AMA's International Medical Graduate, or IMG, Section Governing Council says IMGs are essential to the U.S. primary care health care delivery system.
According to the paper(www.ama-assn.org), "International Medical Graduates in American Medicine: Contemporary Challenges and Opportunities," more IMGs train in primary care specialties and internal medicine subspecialties than do graduates of U.S. medical schools. Moreover, many go on to practice in medically underserved areas, especially remote, rural communities.
"IMGs are an indispensable part of a functional primary health care delivery system," say the paper's authors. "The United States needs to make every effort to attract and retain qualified and skilled candidates for this challenging field of medicine."
With that goal in mind, the paper's authors make a number of recommendations; among them, they call for Congress to increase the number of J-1 visa waiver(travel.state.gov) slots, especially in states with the greatest projected shortages, and for governmental agencies to streamline the visa issuance process.
According to Perry Pugno, M.D., M.P.H., director of the AAFP Division of Medical Education, the position paper is an excellent resource for family medicine residency programs because it gives a history of IMGs in the United States, including insight into the specialties to which they gravitate and the regions in which they are most likely to practice.
Initially developed as a discussion document in 2004, the position paper has been updated each subsequent year. The 2010 paper represents a "thorough revision," say the authors, reflecting current legislative efforts to achieve national health care reform and the recent expansion of U.S. medical schools.
Among facts and figures detailed in the position paper are the following:
- there are 243,457 IMG physicians in the United States, or 26 percent of the total number of physicians, of whom more than 80 percent provide direct patient care;
- 58 percent of IMGs are in primary care, primarily in internal medicine, followed by general/family medicine;
- almost 87 percent of IMGs are age 35 or older, which the report says represents a "graying" of the IMG population that may "presage their ultimate extinction" from the physician workforce -- with adverse public health consequences;
- the top five countries of origin for IMGs are India, the Philippines, Mexico, Pakistan and the Dominican Republic; and
- the top five states in which IMGs practice are New York, California, Florida, New Jersey and Texas.
According to the paper, IMGs have important roles to play in the U.S. health care delivery system by filling access gaps and ensuring the integrity of the so-called health care safety net, especially in poor and rural areas. IMG physicians cluster in counties with such characteristics as an average to below average socioeconomic status, designation as a health professional shortage area(www.hrsa.gov), or HPSA, and a physician-to-population ratio of less than 120:100,000.
By working in HPSAs, IMGs who hold J-1 visas can apply to waive the requirement to return to their home countries. This visa waiver route has become a "major source" of physicians in rural and other HPSAs in the United States, the paper says.
In fact, according to the paper, administrators of health care facilities in such shortage areas turn to the visa waiver system when they can't recruit U.S. medical graduates, or USMGs, for open positions.
When it comes to primary care overall, growth in the subspecialty physician pool far exceeds that seen in family medicine and other primary care specialties, the paper says. In fact, medical student interest in family medicine has declined to "near crisis proportions," as reflected in the declining resident match rates into family medicine programs.
The paper notes that the results of the 2007 resident match showed a decrease for the eighth consecutive year in the number of U.S. seniors from allopathic medical schools selecting primary care.
Pugno is well aware of that decline and what it portends. As he notes in the paper, "It is of concern that since 1988, family medicine has reduced the positions offered by 511, while during that same period, U.S. medical school seniors selecting family medicine declined by 1,047. Currently, three out of five first-year residents in family medicine are IMGs."
AAFP member Raouf Seifeldin, M.D., of Troy, Mich., vice chair of the AMA-IMG Section Governing Council, contributed to the position paper. Seifeldin is a USIMG, which the paper defines as a physician who either was born in the United States or is a naturalized U.S. citizen and who obtained his or her medical education in a foreign medical school.
Seifeldin graduated from the Ain Shams University Faculty of Medicine in Cairo, Egypt, and completed his residency at the Doctors' Hospital of Michigan Family Medicine Residency in Pontiac, where he now practices in a medically underserved community. He told AAFP News Now that, "IMGs in America are part of the solution" to the shortage of primary care physicians.
Seifeldin, who is associate director of the Oakland Physicians Medical Center/Doctors' Hospital of Michigan Family Medicine Residency Program(www.dhofm.com), said all of the 18 resident physicians in his program are IMGs, including two who are USIMGs.
Historically, Seifeldin said, graduates of the residency program have stayed in the area to practice. Some have gone to the rural Upper Peninsula and central areas of Michigan. Some have gone to southern states. A few have continued in a geriatric fellowship at a time when the country needs physicians with such knowledge to care for an aging population, he said.
According to the AMA's paper, in addition to IMGs' willingness to practice in remote, rural areas -- which outstrips that of either USIMGs or USMGs -- they possess a unique knowledge base and skills set that allows them to better understand cross-cultural issues among their patients.
"The diverse backgrounds of IMGs are especially valuable in caring for a multiethnic and increasingly diverse U.S. population," says the paper.