Physician shortages and our increasing dependence on the international medical graduate: is there a mutually beneficial solution?

Differences in duty hours and their relationship with academic parameters between preliminary and categorical general surgery residents

BACKGROUND

There is the perceived notion that nondesignated preliminary general surgery (P-GS) interns are treated differently (i.e., overworked) than their categorical GS (C-GS) counterparts are treated, or in an effort to prove themselves worthy of a categorical position, nondesignated preliminary residents may self-choose to work more. Empirical evidence examining duty-hour differences between P-GS and C-GS residents is lacking.

METHODS

We retrospectively reviewed 4 academic years (July 2009 to June 2013) of our self-entered duty-hour database. Duty hours were averaged over 4-week periods and then averaged annually for each intern. Duty-hour averages and the percentage of conference attendance between P-GS and C-GS interns were compared. Sensitivity analyses were conducted to evaluate the effect of the 2011 duty-hour regulations, attendance to educational activities, seasonal variations in workload, and the Match Day effect.

RESULTS

A total of 70 P-GS and 43 C-GS interns were compared. Duty-hour averages (±standard deviation, range) were 64.4h/wk (±4.6; 45-70) for the P-GS interns and 64.1h/wk (±3.9; 57-72) for the C-GS interns, p = 0.8. Mean (±standard deviation, range) conference attendance was 61% (±17; 33-89) for the P-GS interns and 66% (±18; 44-85) for the C-GS interns (p = 0.13). Duty-hour averages for both the groups positively correlated with conference attendance (r = 0.27, p = <0.001). The P-GS and the C-GS interns worked on average 4.8 hours more a week after the implementation of the 2011 Accreditation Council of Graduate Medical Education duty-hour regulations when compared with before implementation (66.7 ± 4.1 vs 62 ± 3.1, p < 0.0001), with no difference between both the groups. No seasonal variation in duty hours was encountered for either group. For the P-GS interns, no difference in duty hours was observed before or after the Match Day.

CONCLUSIONS

At our institution, the P-GS and the C-GS interns have equivalent duty-hour periods and similar conference attendance. An expected, a positive correlation was observed between duty hours and conference attendance. Average weekly duty hours increased by almost 5 hours after the implementation of the 2011 duty-hour regulations.

Perspective: the need for practice socialization of international medical graduates--an exemplar from pain medicine

One in four actively practicing physicians in the United States is a graduate of an international medical school. International medical graduates (IMGs) account for one-quarter of all visits to office-based physicians in the United States and are more likely than U.S. medical graduates to practice in primary care shortage areas outside of metropolitan statistical areas. IMGs fill critical gaps in the U.S. health system. However, the authors maintain that IMGs face important challenges in transitioning to the U.S. health system. Most debate surrounding IMGs' transition focuses on overcoming cultural and linguistic barriers. Little attention has been paid to the influence of educational and practice socialization of IMGs on their medical encounters and other aspects of their U.S. clinical practice. The existing credentialing requirements do not prepare individuals for unique challenges-presented by the U.S. health system-that IMGs may not be exposed to during medical training or practice in their home countries or countries of training.Anecdotal evidence of the vastly disparate ways in which pain is approached and managed in major source countries of IMGs is a case in point. Using pain treatment as an exemplar, the authors contrast the capacity and emphasis placed on pain treatment in the United States and in major source countries of IMGs to illustrate the special clinical challenges faced by IMGs in their transition to U.S. practice. The authors conclude with recommendations to close this transitional gap, emphasizing the need for targeted assessment and training for IMGs.