International Medical Graduates: Update on
A Diversified Physician Workforce
SELIM KRIM, MD
ASSISTANT PROFESSOR OF MEDICINE
DIVISION OF GENERAL INTERNAL MEDICINE
TEXAS TECH UNIVERSITY HEALTH SCIENCES CENTER
Where I am from
Algeria/Location
Where I was born
Algeria/History
500,000 and 700,000: Homo erectus
10,000 BC: Berbers
1000 BC: Numidia
200 BC: Part of the Western Roman Empire
300 AD: Part of the Byzantine Empire
800 AD: Muslim Arab Armies arrive
1510: Spain takes control
1516: Part of Ottoman Empire
1830: France invades Algeria
1954: Algerian War of Independence
1962: Independence of Algeria
Algeria
Country Name: People's Democratic Republic of Algeria
Government type: Republic
Independence: July 5, 1962
Population: 34,178,188
Age:
26.6 years (median), 65-0ver represent 5% of total
Population
Ethnic groups: Arab-Berber 99%, European less than 1%
Languages: Arabic, French, Berber
Religions: Sunni Muslim (state religion) 97%, Christian and
Jewish 3%
Algiers The White
Our Lady of Africa
Our Lady of Africa
Ketchaoua Mosque
My Journey
Paris
Lubbock
Pittsburgh
Algiers
International Medical
Graduates
Definitions
IMGs are physicians who have completed their medical education
outside the U.S. or Canada. IMGs consist of:
Foreign nationals on special visa status (eg. J1 or H1B)
U.S. citizens or permanent residents who graduated from foreign
medical schools
Where are they coming from?
Zoghbi, W. A. et al. J Am Coll Cardiol 2004;44:245-251
The Educational Commission for
Foreign Medical Graduates (ECFMG)
“ Through its program of certification, the
Educational Commission for Foreign Medical
Graduates (ECFMG®) assesses the readiness of
international medical graduates to enter
residency or fellowship programs in the United
States that are accredited by the Accreditation
Council for Graduate Medical Education
(ACGME).”
ECFMG Certification
 Pass the USMLE:




Medical Science Examination Step 1
Clinical Skills Assessment Step2 (CS)
Clinical Knowledge Assessment Step2
Must pass all exams within a 7 year
period!
 ECFMG Verification of medical diploma with
medical school
The NRMP “Match”
• The National Resident Matching Program (NRMP) is
a private, not-for-profit corporation established
in 1952 to provide a uniform date of appointment
to positions in graduate medical education (GME).
• Each year, the NRMP conducts a residency match
that is designed to optimize the rank ordered
choices of students and program directors.
How many IMGs Apply for PGY1 position?
U.S. NRMP, Match results. 2007
How many IMGs Obtain a PGY1 Position?
U.S. NRMP, Match results. 2007
Challenges
Costs
 The USMLE:
 Medical Science Examination Step 1= $ 710
 Clinical Skills Assessment (Step2 CS)= $ 1200
 Clinical Knowledge Assessment (Step2 CK)= $ 710
 Interviews and travel:
 Program Applications: $ 2000
 Cost of travel for step2 CS: $1000-$2000
Visas
Immigration Laws
• Can affect training of IMGs and chances of
joining the workforce
• Increasingly pose obstacles for international
travel for IMGs and their families
Employment
•
•
Primarily related to visa status
J-1 visa holders are at increasing risk of
not finding waivers, particularly after Sept.
11th
Visas
(Non-Clinical Visa Programs)
• J-1 Research- 5 years maximum potential
duration (Caution: 2-year rule may be
attached)
• H-1B – 6 years maximum duration
• NAFTA – Canadian & Mexican nationals only
Universities, medical schools and research
institutions may offer visa assistance for
research activities
Visas
(Visa Programs for Clinical Training)
J-1 ECFMG (Educational Commission for Foreign
Medical Graduates)
- 7 years maximum potential duration
Caution: 2-year home rule is attached.
•
• H-1B – 6 years maximum duration
Requires all 3 Steps of USMLE
Country of Medical School
Distribution
Patterns of Origins and Destinations
Demographic Characteristics
http://www.fammed.washington.edu/CHWS/
http://www.fammed.washington.edu/CHWS/
Distribution of IMGs in The
U.S. in 2001, by County
http://www.fammed.washington.edu/CHWS/
http://www.fammed.washington.edu/CHWS/
http://www.fammed.washington.edu/CHWS/
Who are the patients of international medical graduates?
• Race/Ethnicity
• Expected source of payment
• Characteristics of patient’s neighborhoods
Who are international medical graduates?
Where do international medical graduates practice?
NCHS Data Brief ■ No. 13 ■ February 2009
Office visits by Patients
Race\Ethnicity
NCHS Data Brief ■ No. 13 ■ February 2009
Office visits by patients’ primary
Expected sources of payment
NCHS Data Brief ■ No. 13 ■ February 2009
Characteristics of patient’s
neighborhoods
NCHS Data Brief ■ No. 13 ■ February 2009
IMG vs. USMG By Race/Ethnicity
NCHS Data Brief ■ No. 13 ■ February 2009
Where do IMG they practice?
NCHS Data Brief ■ No. 13 ■ February 2009
The purpose of this pilot project was to assess IMG
perceptions in two major policy areas:
(a) IMG impact on U.S. healthcare
(b) IMG impact on countries of origin
Impact on U.S. healthcare
S. Agrawal. OPUS 12 Scientist 2008 Vol. 2, No. 1
Impact on Countries of Origin
S. Agrawal. OPUS 12 Scientist 2008 Vol. 2, No. 1
Impact on Countries of Origin
S. Agrawal. OPUS 12 Scientist 2008 Vol. 2, No. 1
Conclusion
• IMGs represent about a quarter of the entire physician workforce
• India, the Philippines, Mexico and the Republic of Korea
remain the leading countries of origin of IMGs
• There have been consistent patterns of IMG origin countries
and destination states
• International medical graduates are more likely to practice
in primary care shortage areas
• They are also more likely to have more Medicaid patients and
minorities
Conclusion
• U.S. health care system continues to rely on international
medical graduates to address primary care physician shortage
outside of urban metropolitan statistical areas
• However our system may face challenges if the future supply
and use of international medical graduates are affected by
changes in visa policy and other programs affecting physician
supply
• New policies may be needed in the future
International Leaders
Huda Zoghbi, MD
Lebanon
Andreas Gruntzig, MD
Germany
SalimYusuf, MD
India
Elias Zerhouni, MD
Algeria
Valentine Fuster, MD, PhD
Spain
“Share our similarities,celebrate our differences”
M. Scott Peck, MD
Thank you