Inclusivity that calls for embracing: The importance of IMGs

International medical graduates are crucial to the practice of health care in America and around the world.

Our membership is diverse, and not all sections of our membership enjoy equal opportunity. Of more than 1 million physicians in the American Medical Association Physician Masterfile, about 25% are international medical graduates (IMGs). This statistic reflects growth by half a percentage point since 2010, but the number of IMGs in practice has grown by nearly 18% since 2010, which is more than the 15% rise in U.S. medical graduates over that same time period. The largest number of IMGs hail from medical schools in India (23%), followed by the Caribbean (18%), Pakistan (6%), the Philippines (6%), and Mexico (5%).

Internal medicine has the largest share with 45,000 IMGs, but in terms of specialty, IMGs are in the greatest numbers in geriatric medicine, where they make up more than half of the active physician workforce. Also interesting to note is that female IMGs have increased from 25% to 45% between 1990 and 2014. In reviewing the geographic spread, 32% of IMGs work in the South, while 28% work in the Northeast, 20% in the Midwest, 17% in the West, and 3% in territories and military bases. About 33% of IMGs work in a hospital setting, group practice follows at 31%, solo- or two-doctor practice constitutes about 20%, and the rest work in managed care, academic, or unclassified settings. About 58% of IMGs were born outside the U.S., and the other 42% of IMGs were born in the U.S. but obtained their medical degrees in another country.

The significance of these statistics lies in the fact that in the field of internal medicine and its subspecialties, one in four physicians is an international medical graduate, which mirrors the demographic profile of ACP's membership. Historically, the most prominent IMG has been Sir William Osler, who immigrated to the United States from Canada and whose observations and quotes have filled books and been frequently used in scholarly treatises. Over the years since, several others of repute have immigrated from all over the world and have and continue to contribute to advances in U.S. medicine today.

A study published Feb. 3, 2017, in The BMJ looked at the quality of care delivered by IMGs and suggested that after adjustment for disease type, severity, and other factors, patients treated by internationally schooled doctors had a slightly but statistically significantly lower 30-day mortality, 11.2% compared with 11.6% for patients who received care from physicians trained in the U.S. More important, many IMGs tend to work in rural and medically underserved areas, often to fulfill visa obligations, thus ensuring access to care for such populations.

Several studies have also looked at the challenges of IMGs finding residency positions and demonstrated that IMGs were three times as likely to be selected into a community program as opposed to a university program. Departmental pressure, institutional priority, and reputational concerns were cited as factors influencing recruitment of IMGs to university programs in a study published Feb. 11 by the Journal of General Internal Medicine. In addition, these physicians in training often face different challenges than physicians in training who have graduated from U.S. medical schools.

In a perspective piece for ACP in 2000, Barbara L. Schuster, MD, MACP, wrote, “The United States is a country of immigrants. The vitality and spirit brought by new Americans add texture to daily life. The diversity of cultures creates complexity and challenge for those in healthcare. International medical graduates (IMGs) bring a wealth of knowledge of disease not often seen in the United States in addition to knowledge of the belief systems of the cultures from which they come. Belief systems have significant impact on health and disease. Having diversity within the healthcare team allows for improved care delivery within a multicultural environment.”

An Oct. 17, 2017, study in Annals of Internal Medicine suggested that of the 80,000 or so academic physicians in the country, more than 18% were international medical graduates. More than 15% of full professors in medical schools in the United States were educated elsewhere, most often in Asia, Western Europe, the Middle East, Latin America, and the Caribbean. Although ineligible for certain National Institutes of Health funding that is granted only to citizens of this country, IMGs still managed, through collaboration, to be primary investigators on 12.5% of grants. They led more than 18% of clinical trials in the United States and were responsible for about 18% of publications in the medical literature.

The authors of the study suggested that, by some metrics, these doctors account for almost one fifth of academic scholarship in the United States. They further suggested that the diversity of American medicine and the conversations, ideas, and breakthroughs this diversity sparks may be one reason for our competitiveness as a global leader in biomedical research and innovation.

Of interest, the United States is not the only country that relies on doctors trained or educated in other countries. We're not even the country with the highest percentage of such physicians. According to the Organization for Economic Co-operation and Development (OECD), almost 58% of physicians practicing in Israel are international medical graduates, while about 40% of the doctors in New Zealand and Ireland were trained outside those countries. Other countries with an international physician workforce include the U.K., Germany, Australia, France, and Canada.

As we move forward as a country and, closer to home, as an organization, we need to embrace our diversity and afford equal opportunity to all segments of our physician workforce, as well as our membership. The College's 2008 position paper on the role of IMGs in the U.S. physician workplace sums it up best when it states, “With an increasingly diverse ethnic and racial patient population in the United States, the physician population must become equally diverse in order to provide culturally competent care. IMGs contribute greatly to the diversity of the U.S. physician workforce. The College supports measures to improve conditions for those IMGs seeking to train and/or practice in the United States.”