The United States' policies regarding international medical graduates (IMGs) have been hotly debated1,2 since the number of IMGs entering training more than doubled from 1988 to 1994.3 In the 1998-1999 academic year, IMGs added an additional 29% (5134) to the 18,000 US medical graduates entering allopathic and osteopathic training programs.4
This influx of IMGs into training programs comes at a time of widespread concern about a potential surplus of physicians and about rising costs of Medicare reimbursement to teaching hospitals for graduate medical education (GME). As a result, some workforce and professional groups have called for restrictions on the numbers of IMGs permitted to enter training and to remain permanently in the United States.5 However, others argue that IMGs have historically filled gaps in the physician workforce by practicing in geographic areas where US medical graduates (USMGs) prefer not to practice and by choosing specialties that USMGs do not wish to enter.6,7
As a major center for GME in the United States, the state of New York provides a useful window into the experiences of newly trained physicians. Although only 7% of the US population resided in New York in 1999, nearly 15% of all allopathic residents and 29% of all IMG residents trained in New York during that year.4 A survey of residents completing training in New York therefore provides a meaningful perspective on the practice patterns and job market experience of both IMGs and USMGs.
Based on data from teaching hospitals and the American Medical Association's (AMA's) GME database, the Center for Health Workforce Studies at the University at Albany determined the number of physicians expected to complete an allopathic or osteopathic residency program in New York state in 1999. Excluding those in preliminary and transitional programs, approximately 4700 residents in 1140 programs were found to be in their last year of training in New York.
A survey with questions addressing the demographic characteristics, educational experiences, postresidency plans, and job market prospects of graduating residents was mailed to all teaching hospitals in New York State. The hospitals distributed the surveys to individual allopathic and osteopathic residency programs, with instructions to distribute them to residents during their last 6 weeks of training. When completed, the surveys were sent back to the Center by the same route.
The Center received completed surveys from more than 3400 residents for a response rate of 73%. The response rate for residents in primary care fields (family practice, general internal medicine, pediatrics, and internal medicine and pediatrics combined) was 77%. Of the respondents, approximately 48% were USMGs; 52% were IMGs.
The demographic characteristics of the survey respondents closely matched those reported in the AMA GME database for residents completing training in New York in 1999. In particular, the percentages of survey respondents who were IMGs versus USMGs were consistent with those documented in the AMA GME database. This led the authors to conclude that the survey respondents were representative of all residents completing training in New York during the year of study.
Four distinct groups of IMGs were distinguished on the basis of citizenship status: naturalized citizens/permanent residents (45% of IMGs); exchange visitor physicians with J visas (41%); physicians with temporary worker H visas (7%); and native-born US citizens who had obtained medical education outside the United States (US-IMGs) (7%). As US-IMGs and IMGs who are naturalized citizens or permanent residents enjoy similar immigration status, they were considered as a single group for data analysis. Physicians with J and H visas, both of which are US temporary immigration visas, were also grouped together for the purpose of analysis.
The results of the survey suggest certain trends in the practice and employment characteristics of graduating New York residents based on their citizenship and visa status. IMGs, particularly those with temporary visas, were more likely to train in primary care specialties, internal medicine subspecialties, and psychiatry than were USMGs. For example, 57% of temporary visa-holding IMGs surveyed were completing training in the primary care fields of family practice, general internal medicine, general pediatrics, or internal medicine and pediatrics combined, compared to 37% of USMGs surveyed (P<.001).
IMGs with temporary visas were more likely to subspecialize than were USMGs. For example, 62% of temporary visa-holding IMGs in internal medicine were planning to subspecialize, compared with 36% of USMGs in internal medicine (P<.001). IMGs who were US citizens or permanent residents subspecialized at a similar rate as USMGs (Figure 1). Of all graduating residents with J visas, 18% were planning to leave the United States immediately following completion of training. Excluding those going on to subspecialize, 28% were planning to leave the United States.
USMG indicates US medical graduate; IMG, international medical graduate.
When the numbers of temporary visa-holding IMGs who were subspecializing or departing from the country were taken into account, the percentage of these IMGs actually entering primary care practice in the United States was approximately equal to that of USMGs (36% vs 38%, P=.409) (Table 1).
Of temporary visa holding IMGs with confirmed plans to practice in the United States, 84% were planning to practice in designated health professional shortage areas (HPSAs), compared with only 11% of USMGs (P<.001) and 6% for other IMGs (P<.001). However, when calculated as a percent of all graduating residents regardless of their plans (including graduates that were subspecializing or leaving the country), the percent of J visa physicians planning to practice in HPSAs dropped to 15%, and the figure for USMGs dropped to 5% (P<.001).
Temporary visa-holding IMGs expressed significantly more difficulty finding a satisfactory practice opportunity than did USMGs or permanent residents/US citizen IMGs. For example, 44% of temporary visa-holding IMGs indicated that they had to change their plans because of limited practice opportunities, compared with only 15% (P<.001) for USMGs and 24% (P<.001) for other IMGs.
The results of this survey indicate that international and US medical graduates in New York State differ significantly in their training and practice characteristics. In addition, significant variations in posttraining plans appear to exist among IMGs, depending on their specific citizenship and visa status.
While it may be that IMGs entering primary care fields are filling a gap created by USMGs, the high percentage of IMGs in certain subspecialties also reflects their willingness to enter specialties that allow them to remain in this country while in training, even if demand for their services is low.
The results of this study indicate that IMGs holding temporary visas are more likely than other IMGs to practice in health profession shortage areas. Given the higher proportion of IMGs with temporary visas who plan to subspecialize or to return to their native country after completing their primary care training, the contribution of IMGs to primary care in underserved areas is not as dramatic as was previously thought.
Although US-IMGs and IMGs who are naturalized citizens or permanent residents are more likely than temporary visa-holding IMGs or USMGs to enter primary care specialties without subspecializing, few of them appear to go on to work in designated medically underserved areas and thus may not contribute to primary care in those areas as may have been thought.
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