Patients of family physicians and two other medical specialty groups who graduated from international medical schools and who were not U.S. citizens had lower mortality rates for certain conditions when compared with matched patients cared for by U.S.-educated physicians, a recent study found. When the study researchers compared outcomes for all international medical graduates, or IMGs -- regardless of citizenship -- with those for all U.S. medical school graduates, there was virtually no difference in patient mortality rates.
"It is reassuring that international graduates are comparable to U.S. graduates in terms of patient mortality, because they (IMGs) constitute nearly a quarter of the physicians in the United States," said researchers at the Foundation for Advancement of International Medical Education and Research in Philadelphia in the study(content.healthaffairs.org), which was published in the August issue of Health Affairs.
"These findings are particularly important at a time when there is an impending shortage of physicians in the United States, and international graduates are one way of addressing the shortfall," the researchers noted.
Suben Naidu, M.D., M.P.H., of Edmond, Okla., an IMG co-convener for the 2010 AAFP National Conference of Special Constituencies, said the study results should come as no surprise.
"It is common knowledge that non-American IMGs often are well-trained and leading clinicians in their countries of origin," he told AAFP News Now. "The rigorous credentialing process (in the United States) self-selects these leading clinicians and allows them to perform very well.
"Often, the non-American IMGs have a fair amount of practical experience, as well as experience in other disciplines, prior to entering primary care in the United States," Naidu added. "They invest tremendous effort, in multiple processes, to ensure their success here."
According to the Health Affairs study, some academicians have expressed concern about the quality of care provided by physicians who have been educated abroad. To determine if that concern is warranted, researchers examined more than 244,000 hospitalizations in Pennsylvania between 2003 and 2006 to assess whether mortality rates and lengths-of-stay varied according to the physicians' citizenship and location of medical school training.
The researchers focused on the hospitalizations of patients with congestive heart failure or acute myocardial infarction and their care by three groups of specialists: family physicians, internists and cardiologists. The more than 6,100 physicians involved in the study were divided into three categories: non-U.S. citizen international medical graduates, or IMGs; U.S. citizen IMGs; and U.S. medical school graduates.
The researchers used records from the Pennsylvania Health Care Cost Containment Council and matched that data with data in the 2008 AMA Physician Masterfile, which contains information on all physicians who reside in the United States, and with data in the Educational Commission for Foreign Medical Graduates, or ECFMG, database, which contains information on IMGs who seek residency training in the United States. All analyses were limited to hospitalizations in which the attending physician graduated from medical school after 1958, which was the year in which the ECFMG was established.
For data on mortality, the researchers made four comparisons:
- non-U.S. citizen IMGs and U.S. citizen IMGs with U.S. medical school graduates;
- non-U.S. citizen IMGs with U.S. medical school graduates;
- U.S. citizen IMGs with U.S. medical school graduates; and
- non-U.S. citizen IMGs with U.S. citizen IMGs.
Overall, patient mortality was 5.4 percent -- 3.3 percent among patients with congestive heart failure and 13 percent among those with acute myocardial infarction. The researchers found statistically significant differences among the groups of physicians, however, with patients of non-U.S. citizen IMGs having the lowest mortality levels and patients of U.S. citizen IMGs having the highest.
In fact, care management by non-U.S. citizen IMGs was associated with a 16 percent decrease in mortality relative to that provided by U.S. citizen IMGs and a 9 percent decrease relative to management by U.S. medical school graduates.
"The difference between non-U.S. citizen and U.S. citizen international graduates was striking," said the researchers. "U.S. citizen international graduates have lower scores on the cognitive portions of the licensing examination sequence, lower ratings from training program directors and lower rates of specialty board certification."
According to the study, part of the performance difference may be attributed to variability in the quality of medical schools that U.S. citizen IMGs attend, "but to some degree, it may also reflect their ability."
However, the differences in mortality rates among patients cared for by all IMGs (i.e., U.S. citizen and non-U.S. citizen IMGs) and all U.S. medical school graduates were not statistically significant, the researchers said.
"We found no difference in mortality when comparing all international medical graduates with U.S. graduates. This is consistent with work done in Canada comparing international graduates and Canadian graduates. Moreover, it speaks to the reliability of the U.S. certification process for international medical graduates."
When the researchers analyzed the data for the second variable, lengths of stay, there were statistically significant differences among the groups of physicians.
The mean length of stay was 5.28 days, broken down as 5.12 days for congestive heart failure and 5.86 days for acute myocardial infarction. Overall, the patients of U.S. medical school graduates had shorter lengths of stay than those of either non-U.S. citizen or U.S. citizen IMGs.
The researchers said the study's results may have important implications for non-U.S. citizen IMGs and U.S. citizen IMGs.
"Among international graduates, the apparent superior performance of non-U.S. citizens suggests that policies that affect the size of this group might have implications for quality. Our data also address some of the negative perceptions about the care provided by these physicians.
"In contrast, the apparent performance of U.S. citizens who graduate from international medical schools suggests the importance of further research to clarify whether their performance is a result of their medical education experiences or their ability," the researchers said.