Variations in geographical distribution of foreign and domestically trained physicians in the United States: 'safety nets' or 'surplus exacerbation'?

Whom Do Incentive Program Physicians Serve? New Measures for Assessing Program Reach

One approach to ameliorating health workforce maldistribution is incentivizing health professionals, including physicians, to locate in underserved areas. However, eligibility for programs typically relies on large geographic areas whereas it is subpopulations within underserved areas who are typically at risk. New measures introduced in this article capture data on the patients actually served by incentive program physicians. A pilot study of one state's J-1 Visa Waiver and loan repayment programs validated the new measures of medical need, low income, rural location, and population-to-provider ratios of provider location, providing a nuanced picture of the groups actually served by incentive program physicians.

Characteristics of International Medical Graduates in Academic Plastic Surgery

BACKGROUND

International medical graduates play a significant role in meeting U.S. health care needs, and contribute to a more diverse provider workforce. This study aimed to determine the prevalence, characteristics, and academic productivity of plastic surgery international medical graduate faculty.

METHODS

A cross-sectional study was conducted to compare characteristics of international medical graduates against domestic medical graduates including demographics, trainings, academic ranks, leadership positions, number of publications and citations, and Hirsch index.

RESULTS

International medical graduates represent 10.3 percent of all 918 academic plastic surgeons in the United States, with the majority having graduated from India (16.8 percent), Brazil (8.4 percent), and the United Kingdom (8.4 percent). International medical graduates were more likely to have graduated from independent programs (OR, 5.7; p < 0.0001) and to have completed research fellowship (OR, 2.1; p = 0.0001) and burn fellowship (OR, 6.5; p < 0.0001). Programs led by international medical graduate chairs employed more international medical graduate faculty (21 percent versus 9 percent; p < 0.0001). International medical graduates had comparable Hirsch indices, number of publications, and citations, but received less National Institutes of Health funding ($32,020 versus $223,365). International medical graduates also had comparable rates of attaining leadership positions such as fellowship director and chair but required fewer years of experience to become residency director (8.3 years versus 17.3 years).

CONCLUSIONS

The contribution of international medical graduates in academic plastic surgery was evident based on research productivity, academic ranks, and leadership positions. International medical graduates are more likely to be employed in programs led by international medical graduate chairs. This study may help guide aspiring international medical graduate academics and aid in hiring decisions at academic institutions.

Incorporating Medical Supply and Demand into the Index of Physician Maldistribution Improves the Sensitivity to Healthcare Outcomes

BACKGROUND

Since the association between disparity in physician distribution and specific healthcare outcomes is poorly documented, we aimed to clarify the association between physician maldistribution and cerebrovascular disease (CeVD), a high-priority health outcome in Japan.

METHODS

In this cross-sectional study, we conducted multivariable regression analysis with the Physician Uneven Distribution Index (PUDI), a recently developed and adopted policy index in Japan that uniquely incorporates the gap between medical supply and demand, as the independent variable and CeVD death rate as the dependent variable. Population density, mean annual income, and prevalence of hypertension were used as covariates.

RESULTS

The coefficient of the PUDI for the CeVD death rate was -0.34 (95%CI: -0.49--0.19) before adjusting for covariates and was -0.19 (95%CI: -0.30--0.07) after adjusting. The adjusted R squared of the analysis for the PUDI was 0.71 in the final model. However, the same multivariable regression model showed that the number of physicians per 100,000 people (NPPP) was not associated with the CeVD death rates before or after adjusting for the covariates.

CONCLUSION

Incorporating the gap between the medical supply and demand in physician maldistribution indices could improve the responsiveness of the index for assessing the disparity in healthcare outcomes.

Nativity status and workplace discrimination in registered nurses: Testing the mediating role of psychosocial work characteristics

AIM

To examine: (a) whether nativity status was associated with workplace discrimination, and (b) whether this association was mediated through psychosocial work characteristics (job strain, job demands, and job control) among registered female nurses.

DESIGN

Cross-sectional survey with a self-report questionnaire was conducted.

METHODS

A random sample of 610 native Registered Nurses and a total sample of 188 foreign-born Registered Nurses working in Finland were used. Data were collected between September-November of 2017 and analysed using a counterfactual approach in the causal mediation framework.

RESULTS

After adjusting for several potential confounders, foreign-born nurses scored higher on workplace discrimination than native nurses. Approximately 20% of the association between nativity status and workplace discrimination was mediated through job control. Job demands and job strain were unlikely to mediate this association.

CONCLUSION

The study provides further evidence that migrant status is associated with a higher risk of workplace discrimination among nurses. Lower levels of control over one's own job may partly contribute to the higher risk of workplace discrimination in foreign-born women nurses.

IMPACT

Our study addresses the relationship between nativity status and workplace discrimination among female nurses and its mediating factors. The findings suggest that healthcare organization leaders need to be aware of the increased risk of workplace discrimination among migrant nurses. Moreover, healthcare organizations need to consider psychosocial work characteristics, including job control, in the efforts aimed to prevent and reduce discrimination against their foreign-born employees.

Geographic variation in spatial accessibility of U.S. healthcare providers

BACKGROUND

Growing physician maldistribution and population demographic shifts have contributed to large geographic variation in healthcare access and the emergence of advanced practice providers as contributors to the healthcare workforce. Current estimates of geographic accessibility of physicians and advanced practice providers rely on outdated "provider per capita" estimates that have shortcomings.

PURPOSE

To apply state of the art methods to estimate spatial accessibility of physician and non-physician clinician groups and to examine factors associated with higher accessibility.

METHODS

We used a combination of provider location, medical claims, and U.S. Census data to perform a national study of health provider accessibility. The National Plan and Provider Enumeration System was used along with Medicare claims to identify providers actively caring for patients in 2014 including: primary care physicians (i.e., internal medicine and family medicine), specialists, nurse practitioners, and chiropractors. For each U.S. ZIP code tabulation area, we estimated provider accessibility using the Variable-distance Enhanced 2 step Floating Catchment Area method and performed a Getis-Ord Gi* analysis for each provider group. Generalized linear models were used to examine associations between population characteristics and provider accessibility.

RESULTS

National spatial patterns of the provider groups differed considerably. Accessibility of internal medicine most resembled specialists with high accessibility in urban locales, whereas relative higher accessibility of family medicine physicians was concentrated in the upper Midwest. In our adjusted analyses independent factors associated with higher accessibility were very similar between internal medicine physicians and specialists-presence of a medical school in the county was associated with approximately 70% higher accessibility and higher accessibility was associated with urban locales. Nurse practitioners were similar to family medicine physicians with both having higher accessibility in rural locales.

CONCLUSIONS

The Variable-distance Enhanced 2 step Floating Catchment Area method is a viable approach to measure spatial accessibility at the national scale.

Supply, distribution and characteristics of international medical graduates in family medicine in the United States: a cross-sectional study

Background

To describe the supply, distribution, and characteristics of international medical graduates (IMGs) in family medicine who provide patient care in the U.S.

Methods

A cross-sectional study design, using descriptive statistics on combined data from the Educational Commission for Foreign Medical Graduates and the American Medical Association, including medical school attended, country of medical school, and citizenship when entering medical school.

Results

In total, 118,817 physicians in family medicine were identified, with IMGs representing 23.8% (n = 28,227) of the U.S. patient care workforce. Of all 9579 residents in family medicine, 36.0% (n = 3452) are IMGS. In total, 35.9% of IMGs attended medical school in the Caribbean (n = 10,136); 19.9% in South-Central Asia (n = 5607) and 9.1% in South-Eastern Asia (n = 2565). The most common countries of medical school training were Dominica, Mexico, and Sint Maarten. Of all IMGs in family medicine who attended medical school in the Caribbean, 74.5% were U.S. citizens. In total, 40.5% of all IMGs in family medicine held U.S. citizenship at entry to medical school. IMGs comprise almost 40% of the family medicine workforce in Florida, New Jersey and New York.

Conclusions

IMGs play an important role in the U.S. family medicine workforce. Many IMGs are U.S. citizens who studied abroad and then returned to the U.S. for graduate training. Given the shortage of family physicians, and the large number of IMGs in graduate training programs, IMGs will continue to play a role in the U.S. physician workforce for some time to come. Many factors, including the supply of residency training positions, could eventually restrict the number of IMGs entering the U.S., including those contributing to family practice.

International Medical Graduates in Nephrology: Roles, Rules, and Future Risks

International medical graduates (IMGs) have become an increasingly essential part of many residency and fellowship programs in the United States. IMGs, who may be of either US or non-US citizenship, contribute significantly to the physician workforce across this country, particularly in underserved areas, as well as in their home countries on their return after training. Approximately 65% of nephrology fellows are IMGs, with most of these being non-US citizens. Non-US IMG applications for nephrology fellowship have been declining, exacerbating an ongoing shortage of nephrology trainees. IMGs face visa status restrictions and immigration policy concerns, limitations on federally funded research support, and difficulty finding desirable jobs in both private practices and academia after fellowship. We review training, examination, and licensure requirements, as well as visa status rules for IMGs. We also discuss the potential negative impact of recent immigration policies limiting the entry of non-US IMGs on the medical community in general and in nephrology in particular.

Acculturation Needs of Pediatric International Medical Graduates: A Qualitative Study

Phenomenon: International medical graduates (IMGs) play a key role in host countries' health systems but face unique challenges, which makes effective, tailored support for IMGs essential. Prior literature describing the acculturation needs of IMGs focused primarily on communication content and style. We conducted a qualitative study to explore acculturation that might be specific to IMG residents who care for children.

APPROACH

In a study conducted from November 2011 to April 2012, we performed four 90-minute semistructured focus groups with 26 pediatric IMG residents from 12 countries. The focus group transcripts were analyzed using open and focused coding methodology.

FINDINGS

The focus groups and subsequent analysis demonstrated that pediatric IMG residents' socialization to their home culture impacts their transition to practice in the United States; they must adjust not only to a U.S. culture, different from their own, but also to the culture of medicine in the United States. We identified the following new acculturation themes: understanding the education system and family structure, social determinants of health, communication with African American parents, contraception, physician handoffs, physicians' role in prevention, adolescent health, and physicians' role in child advocacy. We further highlight the acculturation challenges faced by pediatric IMG residents and offer brief recommendations for the creation of a deliberate acculturation curriculum for pediatric IMG residents. Insight: Residency training is a unique period in physicians' personal and professional development and can be particularly challenging for IMGs. There is a significant gap in the identified acculturation needs and the current curricula available to IMG residents who care for children.

Predictors of Primary Care Physician Practice Location in Underserved Urban or Rural Areas in the United States: A Systematic Literature Review

PURPOSE

The authors conducted a systematic review of the medical literature to determine the factors most strongly associated with localizing primary care physicians (PCPs) in underserved urban or rural areas of the United States.

METHOD

In November 2015, the authors searched databases (MEDLINE, ERIC, SCOPUS) and Google Scholar to identify published peer-reviewed studies that focused on PCPs and reported practice location outcomes that included U.S. underserved urban or rural areas. Studies focusing on practice intentions, nonphysicians, patient panel composition, or retention/turnover were excluded. They screened 4,130 titles and reviewed 284 full-text articles.

RESULTS

Seventy-two observational or case-control studies met inclusion criteria. These were categorized into four broad themes aligned with prior literature: 19 studies focused on physician characteristics, 13 on financial factors, 20 on medical school curricula/programs, and 20 on graduate medical education (GME) programs. Studies found significant relationships between physician race/ethnicity and language and practice in underserved areas. Multiple studies demonstrated significant associations between financial factors (e.g., debt or incentives) and underserved or rural practice, independent of preexisting trainee characteristics. There was also evidence that medical school and GME programs were effective in training PCPs who locate in underserved areas.

CONCLUSIONS

Both financial incentives and special training programs could be used to support trainees with the personal characteristics associated with practicing in underserved or rural areas. Expanding and replicating medical school curricula and programs proven to produce clinicians who practice in underserved urban or rural areas should be a strategic investment for medical education and future research.

Evaluating the effects of Australian policy changes on human capital: the role of a graduate visa scheme

High-skilled migration across international borders is becoming increasingly important in policy and academic debates. In Australia, the recognition of the importance of attracting and retaining highly skilled individuals has stimulated fundamental shifts in immigration policies. This paper explores the impacts of one of these policy shifts in focusing on the introduction of a graduate visa scheme. The scheme was introduced in Australia for the first time in September 2007 offering international graduates from Australian universities 18 months of working rights post-graduation. Since the implementation of this visa scheme there has been a sharp increase in the number of overseas graduates staying in Australia. However, no research has been carried out that investigates the working conditions and interregional migration patterns of these graduates remaining in Australia under this temporary 18 months visa. Through the exploration of individual survey data describing the 2005 and 2008 cohorts of graduates representing the ‘before’ and ‘after’ the graduate visa scheme introduction this paper explores the impact of the visa scheme through analysing and comparing the working conditions and migration patterns of two cohorts of graduates. Findings suggest that although the introduction of the graduate visa scheme attracted more international students/graduates into the country, our analysis highlighted that the average working conditions of the international graduates who decided to remain in Australia worsened. Comparing these results with their domestic (Australian) graduate counterparts revealed that this was not due to the overall state of the Australian economy over the period under consideration.

Monitoring Sub-Saharan African physician migration and recruitment post-adoption of the WHO code of practice: temporal and geographic patterns in the United States

Data monitoring is a key recommendation of the WHO Global Code of Practice on the International Recruitment of Health Personnel, a global framework adopted in May 2010 to address health workforce retention in resource-limited countries and the ethics of international migration. Using data on African-born and African-educated physicians in the 2013 American Medical Association Physician Masterfile (AMA Masterfile), we monitored Sub-Saharan African (SSA) physician recruitment into the physician workforce of the United States (US) post-adoption of the WHO Code of Practice. From the observed data, we projected to 2015 with linear regression, and we mapped migrant physicians' locations using GPS Visualizer and ArcGIS. The 2013 AMA Masterfile identified 11,787 active SSA-origin physicians, representing barely 1.3% (11,787/940,456) of the 2013 US physician workforce, but exceeding the total number of physicians reported by WHO in 34 SSA countries (N = 11,519). We estimated that 15.7% (1,849/11,787) entered the US physician workforce after the Code of Practice was adopted. Compared to pre-Code estimates from 2002 (N = 7,830) and 2010 (N = 9,938), the annual admission rate of SSA émigrés into the US physician workforce is increasing. This increase is due in large part to the growing number of SSA-born physicians attending medical schools outside SSA, representing a trend towards younger migrants. Projection estimates suggest that there will be 12,846 SSA migrant physicians in the US physician workforce in 2015, and over 2,900 of them will be post-Code recruits. Most SSA migrant physicians are locating to large urban US areas where physician densities are already the highest. The Code of Practice has not slowed the SSA-to-US physician migration. To stem the physician "brain drain", it is essential to incentivize professional practice in SSA and diminish the appeal of US migration with bolder interventions targeting primarily early-career (age ≤ 35) SSA physicians.

Policy solutions to address the foreign-educated and foreign-born health care workforce in the United States

Foreign-educated and foreign-born health workers constitute a sizable and important portion of the US health care workforce. We review the distribution of these workers and their countries of origin, and we summarize the literature concerning their contributions to US health care. We also report on these workers' experiences in the United States and the impact their migration has on their home countries. Finally, we present policy strategies to increase the benefits of health care worker migration to the United States while mitigating its negative effects on the workers' home countries. These strategies include attracting more people with legal permanent residency status into the health workforce, reimbursing home countries for the cost of educating health workers who subsequently migrate to the United States, improving policies to facilitate the entry of direct care workers into the country, advancing efforts to promote and monitor ethical migration and recruitment practices, and encouraging the implementation of programs by US employers to improve the experience of immigrating health workers.

Inflows of foreign-born physicians and their access to employment and work experiences in health care in Finland: qualitative and quantitative study

BACKGROUND

In many developed countries, including Finland, health care authorities customarily consider the international mobility of physicians as a means for addressing the shortage of general practitioners (GPs). This study i) examined, based on register information, the numbers of foreign-born physicians migrating to Finland and their employment sector, ii) examined, based on qualitative interviews, the foreign-born GPs' experiences of accessing employment and work in primary care in Finland, and iii) compared experiences based on a survey of the psychosocial work environment among foreign-born physicians working in different health sectors (primary care, hospitals and private sectors).

METHODS

Three different data sets were used: registers, theme interviews among foreign-born GPs (n = 12), and a survey for all (n = 1,292; response rate 42%) foreign-born physicians living in Finland. Methods used in the analyses were qualitative content analysis, analysis of covariance, and logistic regression analysis.

RESULTS

The number of foreign-born physicians has increased dramatically in Finland since the year 2000. In 2000, a total of 980 foreign-born physicians held a Finnish licence and lived in Finland, accounting for less than 4% of the total number of practising physicians. In 2009, their proportion of all physicians was 8%, and a total of 1,750 foreign-born practising physicians held a Finnish licence and lived in Finland. Non-EU/EEA physicians experienced the difficult licensing process as the main obstacle to accessing work as a physician. Most licensed foreign-born physicians worked in specialist care. Half of the foreign-born GPs could be classified as having an 'active' job profile (high job demands and high levels of job control combined) according to Karasek's demand-control model. In qualitative interviews, work in the Finnish primary health centres was described as multifaceted and challenging, but also stressful.

CONCLUSIONS

Primary care may not be able in the long run to attract a sufficient number of foreign-born GPs to alleviate Finland's GP shortage, although speeding up the licensing process may bring in more foreign-born physicians to work, at least temporarily, in primary care. For physicians to be retained as active GPs there needs to be improvement in the psychosocial work environment within primary care.

Employment, psychosocial work environment and well-being among migrant and native physicians in Finnish health care

BACKGROUND

Although international migration of physicians is increasing, research information on their adjustment to working in a new country is scarce. This study examined the differences in employment, perceptions of psychosocial work environment and well-being between migrant and native physicians in Finland.

METHODS

A cross-sectional survey was sent to a random sample of physicians in Finland (N = 7000) and additionally to all foreign-born physicians licensed to practice in Finland (N = 1292). The final response rates were 56% (n = 3646) among native Finns and 43% (n = 553) among foreign-born physicians.

RESULTS

Migrant physicians worked more often in primary care and on-call services and less often in leadership positions than native Finns. They more often experienced lack of professional support and lower work-related well-being compared with native Finns. Those migrant physicians who had lived for a shorter time in Finland perceived less stress related to electronic patient records systems and higher organizational justice compared with native physicians or those foreign physicians who had migrated earlier.

CONCLUSIONS

Foreign-born physicians are more often employed in the primary care sector, where there are most difficulties in recruiting from the native workforce in Finland. Attention should be paid to enhancing equitable career opportunities and well-being among foreign-born physicians working in Finnish health care. Although migrant physicians are relatively well adjusted to Finnish health care in terms of perceptions of psychosocial work environment, their lower well-being calls for attention.

Is working in culturally diverse working environment associated with physicians' work-related well-being? A cross-sectional survey study among Finnish physicians

International mobility of health care professionals is increasing, though little is known about how working in a culturally diverse team affects the native physicians' psychosocial work environment. We examined Finnish physicians' perceptions of work-related wellbeing according to whether they had foreign-born colleagues (FBCs) in their work unit. We also examined whether work-related resources moderate the potential association between work-related wellbeing and working alongside FBCs. A cross-sectional survey was conducted for a random sample of physicians in Finland in 2010 (3826 respondents, response rate 55%). Analyses were restricted to native Finnish physicians working in public health care. The results were analyzed by ANCOVA. In unadjusted analyses, having FBCs was related to poor team climate (p<0.001) and poor job satisfaction (p=0.001). Those physicians who reported high procedural justice and high job control perceived also higher job satisfaction even if they had many FBCs in the work unit (p=0.007 for interaction between FBCs and procedural justice and p<0.001 for interaction between FBCs and job control). These associations were robust to adjustments for age, sex, health care sector, specialization, on-call duty, employment contract, full-time employment and leadership position. The results indicate that culturally diverse work units face challenges related to team climate and job satisfaction. The results also show that leadership plays an important role in culturally diverse work units. The potential challenges of culturally diverse teams for native physicians may be reduced by fair decision-making and by increasing physicians' job control.

Physician emigration from sub-Saharan Africa to the United States: analysis of the 2011 AMA physician masterfile

BACKGROUND

The large-scale emigration of physicians from sub-Saharan Africa (SSA) to high-income nations is a serious development concern. Our objective was to determine current emigration trends of SSA physicians found in the physician workforce of the United States.

METHODS AND FINDINGS

We analyzed physician data from the World Health Organization (WHO) Global Health Workforce Statistics along with graduation and residency data from the 2011 American Medical Association Physician Masterfile (AMA-PM) on physicians trained or born in SSA countries who currently practice in the US. We estimated emigration proportions, year of US entry, years of practice before emigration, and length of time in the US. According to the 2011 AMA-PM, 10,819 physicians were born or trained in 28 SSA countries. Sixty-eight percent (n = 7,370) were SSA-trained, 20% (n = 2,126) were US-trained, and 12% (n = 1,323) were trained outside both SSA and the US. We estimated active physicians (age ≤ 70 years) to represent 96% (n = 10,377) of the total. Migration trends among SSA-trained physicians increased from 2002 to 2011 for all but one principal source country; the exception was South Africa whose physician migration to the US decreased by 8% (-156). The increase in last-decade migration was >50% in Nigeria (+1,113) and Ghana (+243), >100% in Ethiopia (+274), and >200% (+244) in Sudan. Liberia was the most affected by migration to the US with 77% (n = 175) of its estimated physicians in the 2011 AMA-PM. On average, SSA-trained physicians have been in the US for 18 years. They practiced for 6.5 years before US entry, and nearly half emigrated during the implementation years (1984-1999) of the structural adjustment programs.

CONCLUSION

Physician emigration from SSA to the US is increasing for most SSA source countries. Unless far-reaching policies are implemented by the US and SSA countries, the current emigration trends will persist, and the US will remain a leading destination for SSA physicians emigrating from the continent of greatest need. Please see later in the article for the Editors' Summary.

What influences national and foreign physicians' geographic distribution? An analysis of medical doctors' residence location in Portugal

BACKGROUND

The debate over physicians' geographical distribution has attracted the attention of the economic and public health literature over the last forty years. Nonetheless, it is still to date unclear what influences physicians' location, and whether foreign physicians contribute to fill the geographical gaps left by national doctors in any given country. The present research sets out to investigate the current distribution of national and international physicians in Portugal, with the objective to understand its determinants and provide an evidence base for policy-makers to identify policies to influence it.

METHODS

A cross-sectional study of physicians currently registered in Portugal was conducted to describe the population and explore the association of physician residence patterns with relevant personal and municipality characteristics. Data from the Portuguese Medical Council on physicians' residence and characteristics were analysed, as well as data from the National Institute of Statistics on municipalities' population, living standards and health care network. Descriptive statistics, chi-square tests, negative binomial and logistic regression modelling were applied to determine: (a) municipality characteristics predicting Portuguese and International physicians' geographical distribution, and; (b) doctors' characteristics that could increase the odds of residing outside the country's metropolitan areas.

RESULTS

There were 39,473 physicians in Portugal in 2008, 51.1% of whom male, and 40.2% between 41 and 55 years of age. They were predominantly Portuguese (90.5%), with Spanish, Brazilian and African nationalities also represented. Population, Population's Purchasing Power, Nurses per capita and Municipality Development Index (MDI) were the municipality characteristics displaying the strongest association with national physicians' location. For foreign physicians, the MDI was not statistically significant, while municipalities' foreign population applying for residence appeared to be an additional positive factor in their location decisions. In general, being foreigner and male resulted to be the physician characteristics increasing the odds of residing outside the metropolitan areas. However, among the internationals, older doctors were more likely to reside outside metropolitan areas. Being Spanish or Brazilian (but not of African origin) was found to increase the odds of being based outside the Lisbon and Oporto metropolitan areas.

CONCLUSIONS

The present study showed the relevance of studying one country's physician population to understand the factors driving national and international doctors' location decisions. A more nuanced understanding of national and foreign doctors' location appears to be needed to design more effective policies to reduce the imbalance of medical services across geographical areas.

Professional challenges of non-U.S.-born international medical graduates and recommendations for support during residency training

PURPOSE

Despite a long history of international medical graduates (IMGs) coming to the United States for residencies, little research has been done to find systematic ways in which residency programs can support IMGs during this vulnerable transition. The authors interviewed a diverse group of IMGs to identify challenges that might be eased by targeted interventions provided within the structure of residency training.

METHOD

In a qualitative study conducted between March 2008 and April 2009, the authors contacted 27 non-U.S.-born IMGs with the goal of conducting qualitative interviews with a purposeful sample. The authors conducted in-person, in-depth interviews using a standardized interview guide with potential probes. All participants were primary care practitioners in New York, New Jersey, or Connecticut.

RESULTS

A total of 25 IMGs (93%) participated. Interviews and subsequent analysis produced four themes that highlight challenges faced by IMGs: (1) Respondents must simultaneously navigate dual learning curves as immigrants and as residents, (2) IMGs face insensitivity and isolation in the workplace, (3) IMGs' migration has personal and global costs, and (4) IMGs face specific needs as they prepare to complete their residency training. The authors used these themes to inform recommendations to residency directors who train IMGs.

CONCLUSIONS

Residency is a period in which key elements of professional identity and behavior are established. IMGs are a significant and growing segment of the physician workforce. Understanding particular challenges faced by this group can inform efforts to strengthen support for them during postgraduate training.

International medical graduates in the USA: a qualitative study on perceptions of physician migration

Objectives Physician migration from low-income to high-income nations is a global concern. Despite the centrality of understanding the perspectives of international medical graduates (IMGs) who have experienced migration to understanding the causes and consequences of this phenomenon, empirical literature is limited. The authors sought to characterise the experiences of IMGs from limited resource nations currently practicing primary care in the USA, with a focus on their perspectives on physician migration. Design The authors conducted a qualitative study utilising in-depth, in-person interviews and a standardised interview guide. The sample comprised a diverse, purposeful sample of IMGs (n=25) from limited resource nations (defined as having ≤2 physicians per 1000 population). Results Analyses revealed four recurrent and unifying themes reflecting the perspectives of IMGs in the USA on physician migration: (1) decisions to migrate were pragmatic decisions made in the context of individual circumstance; (2) the act of migration ultimately affected participants' ability to return home in multiple, unpredictable ways; (3) the ongoing process of acclimation was coupled with inherent conflicts surrounding the decision to remain in the USA; and (4) the effects of policies in both the home country and in the USA occurred at multiple levels. Conclusion The perspectives of IMGs who have migrated to the USA are an important addition to the ongoing discussion surrounding the global health workforce. Our findings highlight the effects of workforce policies which are often developed and discussed in abstraction, but have real, measurable impacts on the lives of individuals. Future efforts to address physician migration will need to acknowledge the immediate needs of the health workforce as well as the long-term needs of individuals within health systems.

Exploring the potential for foreign-trained dentists to address workforce shortages and improve access to dental care for vulnerable populations in the United States: a case study from Washington State

Background

To address dental workforce shortages in underserved areas in the United States, some States have enacted legislation to make it easier for foreign dental school graduates to become licensed dentists. However, the extent to which foreign dental school graduates will solve the problem of dental workforce shortages is poorly understood. Furthermore, the potential impact that foreign-trained dentists have on improving access to dental care for vulnerable patients living in dental Health Professional Shortage Areas (HPSAs) and those enrolled in public insurance programs, such as Medicaid, is unknown. The objective of this paper is to provide a preliminary understanding of the practice behaviors of foreign-trained dentists. The authors used Washington State as a case study to identify the potential impact foreign dental school graduates have on improving access to dental care for vulnerable populations. The following hypotheses were tested: a) among all newly licensed dentists, foreign-trained dentists are more likely to participate in the Medicaid program than U.S.-trained dentists; and b) among newly licensed dentists who participated in the Medicaid program, foreign-trained dentists are more likely to practice in dental HPSAs than U.S.-trained dentists.

Methods

The authors used dental license and Medicaid license data to compare the proportions of newly licensed, foreign- and U.S.-trained dentists who participated in the Medicaid program and the proportions that practiced in a dental HPSA.

Results

Using bivariate analyses, the authors found that a significantly lower proportion of foreign-trained dentists participated in the Medicaid program than U.S.-trained dentists (12.9% and 22.8%, respectively; P = 0.011). Among newly licensed dentists who participated in the Medicaid program, there was no significant difference in the proportions of foreign- and U.S.-trained dentists who practiced in a dental HPSA (P = 0.683).

Conclusions

Legislation that makes it easier for foreign-trained dentists to obtain licensure is unlikely to address dental workforce shortages or improve access to dental care for vulnerable populations in the United States. Licensing foreign dental school graduates in the United States also has ethical implications for the dental workforces in other countries.

Do international medical graduates (IMGs) "fill the gap" in rural primary care in the United States? A national study

CONTEXT

The contribution that international medical graduates (IMGs) make to reducing the rural-urban maldistribution of physicians in the United States is unclear. Quantifying the extent of such "gap filling" has significant implications for planning IMG workforce needs as well as other state and federal initiatives to increase the numbers of rural providers.

PURPOSE

To compare the practice location of IMGs and US medical graduates (USMGs) practicing in primary care specialties.

METHODS

We used the 2002 AMA physician file to determine the practice location of all 205,063 primary care physicians in the United States. Practice locations were linked to the Rural-Urban Commuting Areas, and aggregated into urban, large rural, small rural, and isolated small rural areas. We determined the difference between the percentage of IMGs and percentage of USMGs in each type of geographic area. This was repeated for each Census Division and state.

FINDINGS

One quarter (24.8% or 50,804) of primary care physicians in the United States are IMGs. IMGs are significantly more likely to be female (31.9% vs 29.9%, P < .0001), older (mean ages 49.7 and 47.1 year, P < .0001), and less likely to practice family medicine (19.0% vs 38%, P < .0001) than USMGs. We found only two Census Divisions in which IMGs were relatively more likely than USMGs to practice in rural areas (East South Central and West North Central). However, we found 18 states in which IMGs were more likely, and 16 in which they were less likely to practice in rural areas than USMGs.

CONCLUSIONS

IMGs fill gaps in the primary care workforce in many rural areas, but this varies widely between states. Policies aimed to redress the rural-urban physician maldistribution in the United States should take into account the vital role of IMGs.

Mammography facilities are accessible, so why is utilization so low?

OBJECTIVE

This study examines new socio-ecological variables reflecting community context as predictors of mammography use.

METHODS

The conceptual model is a hybrid of traditional health-behavioral and socio-ecological constructs with an emphasis on spatial interaction among women and their environments, differentiating between several levels of influence for community context. Multilevel probability models of mammography use are estimated. The study sample includes 70,129 women with traditional Medicare fee-for-service coverage for inpatient and outpatient services, drawn from the SEER-Medicare linked data. The study population lives in heterogeneous California, where mammography facilities are dense but utilization rates are low.

RESULTS

Several contextual effects have large significant impacts on the probability of mammography use. Women living in areas with higher proportions of elderly in poverty are 33% less likely to use mammography. However, dually eligible women living in these poor areas are 2% more likely to use mammography than those without extra assistance living in these areas. Living in areas with higher commuter intensity, higher violent crime rates, greater land use mix (urbanicity), or more segregated Hispanic communities exhibit -14%, -1%, -6%, and -3% (lower) probability of use, respectively. Women living in segregated American Indian communities or in communities where more elderly women live alone exhibit 16% and 12% (higher) probability of use, respectively. Minority women living in more segregated communities by their minority are more likely to use mammography, suggesting social support, but this is significant for Native Americans only. Women with disability as their original reason for entitlement are found 40% more likely to use mammography when they reside in communities with high commuter intensity, suggesting greater ease of transportation for them in these environments.

CONCLUSIONS

Socio-ecological variables reflecting community context are important predictors of mammography use in insured elderly populations, often with larger magnitudes of effect than personal characteristics such as race or ethnicity (-3% to -7%), age (-2%), recent address change (-7%), disability (-5%) or dual eligibility status (-1%). Better understanding of community factors can enhance cancer control efforts.

Importing medicine: a look at citizenship and immigration status for graduating residents in New York State from 1998 to 2007

International medical graduates (IMGs) make up roughly one quarter of the U.S. physician supply and residency training positions. Commentary related to IMGs tends to project a continuing rise in supply over time. This study wanted to challenge these perceptions by disaggregating IMGs by immigration and citizenship status to carefully examine their numerical levels and choices in training specialty and location during a 10-year period. The results demonstrate a shrinking IMG population overall for the state of New York, with noncitizen IMGs shrinking the most markedly. This may bear heavily on New York's physician supply and distribution, particularly for underserved locales. The authors find evidence consistent with some degree of substitution in favor of native-born and naturalized IMGs versus noncitizen IMGs.

Comparison of surgical residency applicants from U.S. medical schools with U.S.-born and foreign-born international medical school graduates

OBJECTIVE

Compare characteristics of U.S. medical school graduates with U.S.-born and foreign-born international medical school (IMG) graduates.

DESIGN

Retrospective analysis.

SETTING

East Carolina University, a tertiary care teaching hospital.

PARTICIPANTS

Demographic data, United States Medical Licensing Examination (USMLE) scores, attempts needed to achieve a passing score, number of scholarly works, attainment of an advanced degree, and employment history since medical school graduation were obtained from all Electronic Residency Application Service applications to a general surgery residency for the 2007 match.

RESULTS

In all, 572 applicants were evaluated. Comparing U.S. graduates with U.S.-born IMGs and foreign-born IMGs. IMGs are older (mean, 28.9 vs 29.9 vs 33.0 years, respectively), more frequently male (70% vs 80% vs 86%, respectively), and hold more advanced degrees (11% vs 13% vs 19%, respectively). Mean time between graduation and application to residency was 0.3 years for U.S. graduates, 1.5 years for U.S.-born IMGs, and 7.7 years for foreign-born IMGs. Although mean USMLE Step 1 scores were similar (206 vs 200 vs 202, respectively), IMGs more frequently required multiple attempts to achieve a passing score (9% vs 20% vs 24%, respectively). Mean USMLE Step 2 scores were lower (213 vs 201 vs 203, respectively), and IMGs again required more attempts to achieve a passing score (11% vs 22% vs 19%, respectively). U.S. graduates produced an average of 1.7 scholarly works compared with 0.9 scholarly works for U.S.-born IMGS and 3.9 scholarly works for foreign-born IMGs. U.S.-born graduates held a mean of 0.3 jobs since graduation with most positions being preliminary surgery residents. U.S.-born IMGs held an average of 2.2 jobs most frequently in research or U.S. preliminary surgery, and foreign-born IMGs held an average of 5.1 jobs; most frequently, positions included international surgery or research.

CONCLUSION

IMGs are older, frequently male, hold more advanced degrees, and produce more scholarly works but require multiple attempts to pass the USMLE. IMGs also hold more jobs after graduation with most positions being in research or surgery.

Heterogeneity in mammography use across the nation: separating evidence of disparities from the disproportionate effects of geography

Background

Mammography is essential for early detection of breast cancer and both reduced morbidity and increased survival among breast cancer victims. Utilization is lower than national guidelines, and evidence of a recent decline in mammography use has sparked concern. We demonstrate that regression models estimated over pooled samples of heterogeneous states may provide misleading information regarding predictors of health care utilization and that comprehensive cancer control efforts should focus on understanding these differences and underlying causal factors. Our study population includes all women over age 64 with breast cancer in the Surveillance Epidemiology and End Results (SEER) cancer registries, linked to a nationally representative 5% reference sample of Medicare-eligible women located in 11 states that span all census regions and are heterogeneous in racial and ethnic mix. Combining women with and without cancer in the sample allows assessment of previous cancer diagnosis on propensity to use mammography. Our conceptual model recognizes the interplay between individual, social, cultural, and physical environments along the pathways to health care utilization, while delineating local and more distant levels of influence among contextual variables. In regression modeling, we assess individual-level effects, direct effects of contextual factors, and interaction effects between individual and contextual factors.

Results

Pooling all women across states leads to quite different conclusions than state-specific models. Commuter intensity, community acculturation, and community elderly impoverishment have significant direct impacts on mammography use which vary across states. Minorities living in isolated enclaves with others of the same race/ethnicity may be either advantaged or disadvantaged, depending upon the place studied.

Conclusion

Careful analysis of place-specific context is essential for understanding differences across communities stemming from different causal factors. Optimal policy interventions to change behavior (improve screening rates) will be as heterogeneous as local community characteristics, so no "one size fits all" policy can improve population health. Probability modeling with correction for clustering of individuals within multilevel contexts can reveal important differences from place to place and identify key factors to inform targeting of specific communities for further study.

How sensitive are multilevel regression findings to defined area of context?: a case study of mammography use in California

The authors develop a hybrid model of health care use that blends features of the traditional Aday-Andersen behavioral model with the socioecological modeling perspective. They use the model to conceptualize the various levels of influence expected from socioecological variables in individuals' mammography use decisions, build contextual variables from fine-grained data into four different types of geographic areas, and then use two- and three-level modeling of personal and area-level contextual factors to explain observed behavior. The central focus is on whether differentiating the conceptualized levels of influence seems to materially affect regression findings. The test could conceivably be confounded by the modifiable areal unit problem, but little evidence for this is found. Findings for California women suggest that distinctions do matter in how the levels of influence are defined for local neighborhood contextual factors. Studies using only county-level contextual factors will miss some meaningful associations related to interpersonal/proximate-level factors.

The TennCare graduate medical education plan: ten years later

BACKGROUND

In 1994, Tennessee converted its Medicaid program to a managed care system--TennCare. Graduate medical education (GME) funding by TennCare was linked to several workforce goals that included increasing the number of residents training in primary care and increasing the number of primary care physicians practicing in underserved areas of Tennessee.

OBJECTIVES

To determine the effects of the TennCare GME plan on GME and the physician workforce of Tennessee.

DESIGN, SETTING, AND PARTICIPANTS

Bureau of TennCare GME data from 1996-2004 and American Medical Association Physician Masterfile data through 2003.

MEASUREMENTS

Changes in filled residency positions and number of stipend supplements awarded after implementation of the TennCare GME plan. Changes in physician workforce characteristics between a 5-year period before and after implementation of TennCare.

RESULTS

Filled primary care residency positions increased from 839 (45.2%) in 1996 to 906 (47.9%) in 2000, but declined to 862 (43.5%) by 2004. Eleven of 133 available primary care stipend supplements were awarded through 2004. The percentage of physicians remaining in Tennessee after completion of residency decreased from 46.2% before TennCare to 42.4% (P = .087) after implementation of TennCare. U.S. medical graduates remaining in state declined by 5.8% (P = .019).

CONCLUSIONS

The major goals of the TennCare GME plan have not been achieved. Overall, physician retention has decreased and the number of U.S. medical graduates remaining in state has declined. State policymakers should consider other methods to increase the number of residents training in primary care and ultimately practicing in underserved areas of Tennessee.

International medical graduates in family medicine in the United States of America: an exploration of professional characteristics and attitudes

BACKGROUND

The number of international medical graduates (IMGs) entering family medicine in the United States of America has steadily increased since 1997. Previous research has examined practice locations of these IMGs and their role in providing care to underserved populations. To our knowledge, research does not exist comparing professional profiles, credentials and attitudes among IMG and United States medical graduate (USMG) family physicians in the United States. The objective of this study is to determine, at the time when a large influx of IMGs into family medicine began, whether differences existed between USMG and IMG family physicians in regard to personal and professional characteristics and attitudes that may have implications for the health care system resulting from the increasing numbers of IMGs in family medicine in the United States.

METHODS

This is a secondary data analysis of the 1996-1997 Community Tracking Study (CTS) Physician Survey comparing 2360 United States medical graduates and 366 international medical graduates who were nonfederal allopathic or osteopathic family physicians providing direct patient care for at least 20 hours per week.

RESULTS

Compared to USMGs, IMGs were older (p < 0.001) and practised in smaller (p = 0.0072) and younger practices (p < 0.001). Significantly more IMGs practised in metropolitan areas versus rural areas (p = 0.0454). More IMG practices were open to all new Medicaid (p = 0.018) and Medicare (p = 0.0451) patients, and a greater percentage of their revenue was derived from these patients (p = 0.0020 and p = 0.0310). Fewer IMGs were board-certified (p < 0.001). More IMGs were dissatisfied with their overall careers (p = 0.0190). IMGs and USMGs did not differ in terms of self-rated ability to deliver high-quality care to their patients (p = 0.4626). For several of the clinical vignettes, IMGs were more likely to order tests, refer patients to specialists or require office visits than USMGs.

CONCLUSION

There are significant differences between IMG and USMG family physicians' professional profiles and attitudes. These differences from 1997 merit further exploration and possible follow-up, given the increased proportion of family physicians who are IMGs in the United States.

Spatial analysis of elderly access to primary care services

BACKGROUND

Admissions for Ambulatory Care Sensitive Conditions (ACSCs) are considered preventable admissions, because they are unlikely to occur when good preventive health care is received. Thus, high rates of admissions for ACSCs among the elderly (persons aged 65 or above who qualify for Medicare health insurance) are signals of poor preventive care utilization. The relevant geographic market to use in studying these admission rates is the primary care physician market. Our conceptual model assumes that local market conditions serving as interventions along the pathways to preventive care services utilization can impact ACSC admission rates.

RESULTS

We examine the relationships between market-level supply and demand factors on market-level rates of ACSC admissions among the elderly residing in the U.S. in the late 1990s. Using 6,475 natural markets in the mainland U.S. defined by The Health Resources and Services Administration's Primary Care Service Area Project, spatial regression is used to estimate the model, controlling for disease severity using detailed information from Medicare claims files. Our evidence suggests that elderly living in impoverished rural areas or in sprawling suburban places are about equally more likely to be admitted for ACSCs. Greater availability of physicians does not seem to matter, but greater prevalence of non-physician clinicians and international medical graduates, relative to U.S. medical graduates, does seem to reduce ACSC admissions, especially in poor rural areas.

CONCLUSION

The relative importance of non-physician clinicians and international medical graduates in providing primary care to the elderly in geographic areas of greatest need can inform the ongoing debate regarding whether there is an impending shortage of physicians in the United States. These findings support other authors who claim that the existing supply of physicians is perhaps adequate, however the distribution of them across the landscape may not be optimal. The finding that elderly who reside in sprawling urban areas have access impediments about equal to residents of poor rural communities is new, and demonstrates the value of conceptualizing and modelling impedance based on place and local context.

Delving below the surface. Understanding how race and ethnicity influence relationships in health care

There is increasing evidence that racial and ethnic minority patients receive lower quality interpersonal care than white patients. Therapeutic relationships constitute the interpersonal milieu in which patients are diagnosed, given treatment recommendations, and referred for tests, procedures, or care by consultants in the health care system. This paper provides a review and perspective on the literature that explores the role of relationships and social interactions across racial and ethnic differences in health care. First, we examine the social and historical context for examining differences in interpersonal treatment in health care along racial and ethnic lines. Second, we discuss selected studies that examine how race and ethnicity influence clinician-patient relationships. While less is known about how race and ethnicity influence clinician-community, clinician-clinician, and clinician-self relationships, we briefly examine the potential roles of these relationships in overcoming disparities in health care. Finally, we suggest directions for future research on racial and ethnic health care disparities that uses a relationship-centered paradigm.

Perceived barriers to health care access among rural older adults: a qualitative study

CONTEXT

Many rural elders experience limited access to health care. The majority of what we know about this issue has been based upon quantitative studies, yet qualitative studies might offer additional insight into individual perceptions of health care access.

PURPOSE

To examine what barriers rural elders report when accessing needed health care, including how they cope with the high cost of prescription medication.

METHODS

During Spring 2001, thirteen 90-minute focus groups were conducted in 6 rural West Virginia communities. A total of 101 participants, aged 60 years and older, were asked several culminating questions about their perceptions of health care access.

FINDINGS

Five categories of barriers to health care emerged from the discussions: transportation difficulties, limited health care supply, lack of quality health care, social isolation, and financial constraints. In addition, 6 diverse coping strategies for dealing with the cost of prescription medication were discussed. They included: reducing dosage or doing without, limiting other expenses, relying on family assistance, supplementing with alternative medicine, shopping around for cheapest prices, and using the Veteran's Administration.

CONCLUSIONS

Overall, rural older adults encounter various barriers to accessing needed health care. Qualitative methodology allows rural elders to have a voice to expound on their experiences. Research can contribute valuable information to shape policy by providing a forum where older adults can express their concerns about the current health care delivery system.

The pediatrician workforce: current status and future prospects

The effective and efficient delivery of children's health care depends on the pediatrician workforce. The number, composition, and distribution of pediatricians necessary to deliver this care have been the subject of long-standing policy and professional debate. This technical report reviews current characteristics and recent trends in the pediatric workforce and couples the workforce to a conceptual model of improvement in children's health and well-being. Important recent changes in the workforce include (1) the growth in the number of pediatricians in relation to the child population, (2) increased numbers of female pediatricians and their attainment of majority gender status in the specialty, (3) the persistence of a large number of international medical graduates entering training programs, (4) a lack of ethnic and racial diversity in pediatricians compared with children, and (5) the persistence of marked regional variation in pediatrician supply. Supply models projecting the pediatric workforce are reviewed and generally indicate that the number of pediatricians per child will increase by 50% over the next 20 years. The differing methods of assessing workforce requirements are presented and critiqued. The report finds that the pediatric workforce is undergoing fundamental changes that will have important effects on the professional lives of pediatricians and children's health care delivery.

Workforce issues in rural areas: a focus on policy equity

Rural communities in the United States are served by relatively fewer health care professionals than urban or suburban areas. I review the geographic distribution of 6 classes of health professionals and describe the multiple government and private policies and programs intended to affect their geographic distribution. These programs can be classified into 3 categories--coercive, normative, and utilitarian--that characterize the major policy levers used to influence practice location decisions. Health workforce policies must be normative to ensure equity for rural communities, but goals in this area can be achieved only through a balance of utilitarian and coercive mechanisms.

The migration of physicians from sub-Saharan Africa to the United States of America: measures of the African brain drain

BACKGROUND: The objective of this paper is to describe the numbers, characteristics, and trends in the migration to the United States of physicians trained in sub-Saharan Africa. METHODS: We used the American Medical Association 2002 Masterfile to identify and describe physicians who received their medical training in sub-Saharan Africa and are currently practicing in the USA. RESULTS: More than 23% of America's 771 491 physicians received their medical training outside the USA, the majority (64%) in low-income or lower middle-income countries. A total of 5334 physicians from sub-Saharan Africa are in that group, a number that represents more than 6% of the physicians practicing in sub-Saharan Africa now. Nearly 86% of these Africans practicing in the USA originate from only three countries: Nigeria, South Africa and Ghana. Furthermore, 79% were trained at only 10 medical schools. CONCLUSIONS: Physician migration from poor countries to rich ones contributes to worldwide health workforce imbalances that may be detrimental to the health systems of source countries. The migration of over 5000 doctors from sub-Saharan Africa to the USA has had a significantly negative effect on the doctor-to-population ratio of Africa. The finding that the bulk of migration occurs from only a few countries and medical schools suggests policy interventions in only a few locations could be effective in stemming the brain drain.

Contextual predictors of mental health service use among children open to child welfare

BACKGROUND

Children involved with child welfare systems are at high risk for emotional and behavioral problems. Many children with identified mental health problems do not receive care, especially ethnic/minority children.

OBJECTIVE

To examine how patterns of specialty mental health service use among children involved with child welfare vary as a function of the degree of coordination between local child welfare and mental health agencies.

DESIGN

Specialty mental health service use for 1 year after contact with child welfare was examined in a nationally representative cohort of children aged 2 to 14 years. Predictors of service use were modeled at the child/family and agency/county levels. Child- and agency-level data were collected between October 15, 1999, and April 30, 2001.

SETTING

Ninety-seven US counties.

PARTICIPANTS

A total of 2823 child welfare cases (multiple informants) from the National Survey of Child and Adolescent Well-being and agency-level key informants from the participating counties.

MAIN OUTCOME MEASURES

Specialty mental health service use during the year after contact with the child welfare system.

RESULTS

Only 28.3% of children received specialty mental health services during the year, although 42.4% had clinical-level Child Behavior Checklist scores. Out-of-home placement, age, and race/ethnicity were strong predictors of service use rates, even after controlling for Child Behavior Checklist scores. Increased coordination between local child welfare and mental health agencies was associated with stronger relationships between Child Behavior Checklist scores and service use and decreased differences in rates of service use between white and African American children.

CONCLUSIONS

Younger children and those remaining in their homes could benefit from increased specialty mental health services. They have disproportionately low rates of service use, despite high levels of need. Increases in interagency coordination may lead to more efficient allocation of service resources to children with the greatest need and to decreased racial/ethnic disparities.

Use of deceptive tactics in physician practices: are there differences between international and US medical graduates?

Concerns have been raised about the medical practices of international medical graduates (IMGs) in the United States. This study examined the differences between IMGs and US-trained medical graduates (USMGs) in their attitude toward and utilization of deception in medical practices. A random sample of physicians practicing in the US was surveyed by mail in 1998. The dependent variables of interest included 11 attitudinal and behavioral indicators of deceptive tactics in medical practice. IMGs and USMGs displayed limited difference in their attitudes but some differences in their self-reported use of deceptive tactics in medical practice. IMGs were less likely than USMGs to change the patient's official diagnosis (OR, 0.557; 95% CI, 0.344-0.902) or to withhold a useful service because of utilization rules (OR, 0.612; 95% CI, 0.382-0.979). The hypothesis that IMGs have less appropriate professional standards than USMGs is not supported by this study. Alternative hypotheses, such as IMG familiarity with US health care and legal systems, warrant investigation.

The Role of International Medical Graduates in America's Small Rural Critical Access Hospitals

CONTEXT

Critical access hospitals (CAHs) are a federal Medicare category for isolated rural facilities with 15 or fewer acute care beds that receive cost-based reimbursement from Medicare.

PURPOSE

This study examines the role of foreign-born international medical graduates (IMGs) in the staffing of CAHs.

METHODS

Chief executive officers (CEOs) of CAH facilities answered a telephone survey on their use of IMGs and the characteristics of those IMGs in winter 2002 (388 responded, for a 96% response rate). This descriptive report presents roles and characteristics of IMGs in CAH facilities and the opinions of the CEOs about these practitioners.

FINDINGS

Overall, 1 (24%) in 4 admitting physicians in CAHs are graduates of non-US medical schools (compared with 23% of physicians nationally), although the rates are higher for CAHs in persistent poverty counties, CAHs that report recruitment problems, and CAHs with smaller medical staffs. Hospitals east of the Mississippi River are more heavily reliant on IMGs than hospitals in the west. Most IMGs are internists (59%) and most (61%) come from India, the Philippines, or Pakistan. Hospital administrators rate the clinical skills of their IMGs highly and their interpersonal skills only slightly lower. Almost half of CAH administrators said their communities recruited their first IMGs during or after 1994, the year of pro-IMG legislative changes.

CONCLUSION

IMG physicians play a significant and possibly growing role in staffing CAHs.

International medical graduates and the primary care workforce for rural underserved areas

The proportion of international medical graduates (IMGs) serving as primary care physicians in rural underserved areas (RUAs) has important policy implications. We analyzed the 2000 American Medical Association Masterfile and Area Resource File to calculate the percentage of primary care IMGs, relative to U.S. medical graduates (USMGs), working in RUAs. We found that 2.1 percent of both primary care USMGs and IMGs were in RUAs, where USMGs were more likely to be family physicians but less likely to be internists or pediatricians. IMGs appear to have been no more likely than USMGs were to practice primary care in RUAs, but the distribution by specialty differs.

Initial practice locations of international medical graduates

OBJECTIVE

To examine the influence of place of graduate medical education (GME), state licensure requirements, presence of established international medical graduates (IMGs), and ethnic communities on the initial practice location choices of new IMGs.

DATA SOURCES

The annual Graduate Medical Education (GME) Survey of the American Medical Association (AMA) and the AMA Physician Masterfile.

STUDY DESIGN

We identified 19,940 IMGs who completed GME in the United States between 1989 and 1994 and who were in patient care practice 4.5 years later. We used conditional logit regression analysis to assess the effect of market area characteristics on the choice of practice location. The key explanatory variables in the regression models were whether the market area was in the state of GME, the years of GME required for state licensure, the proportion of IMGs among established physicians, and the ethnic composition of the market area.

PRINCIPAL FINDINGS

The IMGs tended to locate in the same state as their GME training. Foreign-born IMGs were less likely to locate in markets with more stringent licensure requirements, and were more likely to locate in markets with higher proportions of established IMG physicians. The IMGs born in Hispanic or Asian countries were more likely to locate in markets with higher proportions of the corresponding ethnic group.

CONCLUSIONS

Policymakers may influence the flow of new IMGs into states by changing the availability of GME positions. IMGs tend to favor the same markets over time, suggesting that networks among established IMGs play a role in attracting new IMGs. Further, IMGs choose their practice locations based on ethnic matching.

Exclusion of international medical graduates from federal health-care programs

BACKGROUND

The professional standards of international medical graduates have been the subject of controversy, but empirical research on this topic has been limited.

OBJECTIVES

This report considers whether international medical graduates are at greater risk than US medical graduates for exclusion by the federal government from federally funded programs, such as Medicare and Medicaid.

RESEARCH DESIGN

The list of excluded physicians was merged with data regarding 87,729 family and general practice physicians from the American Medical Association Physician Masterfile, 555 of whom were currently excluded. Logistic regression was used to estimate the effect of international medical graduate status on the probability of exclusion, controlling for board-certification status and other physician characteristics. International medical graduates from high-income Organization for Economic Cooperation and Development (OECD) countries are distinguished from other international medical graduates.

RESULTS

The adjusted exclusion rates of international medical graduates from OECD countries were similar to that of US medical graduates. Among board-certified physicians, the relative risk of exclusion of non-OECD international medical graduates was 2.19 (P <0.001) compared with US medical graduates. Board certification had an even stronger association: US medical graduates who had never been board certified had a relative risk of 4.12 (P <0.001) compared with board-certified US medical graduates. The never board-certified relative risk was 1.72 (P <0.001) among non-OECD international medical graduates compared with board-certified graduates. Among physicians who had never been board certified, rates of US and international medical graduates did not differ substantially.

CONCLUSIONS

Further investigation is needed regarding the causal determinants of exclusion disparities. It is unclear to what extent these disparities may reflect differences in ethical conduct, quality of care, or prejudicial enforcement practices, and the extent to which board certification can causally reduce actions leading to exclusion.

Residents' preferences and preparation for caring for underserved populations

Access to care by low-income persons and residents of rural and poor inner-city areas is a persistent problem, yet physicians tend to be maldistributed relative to need. The objectives were to describe preferences of resident physicians to locate in underserved areas and to assess their preparedness to provide service to low-income populations. A national survey was made of residents completing their training in eight specialties at 162 US academic health center hospitals in 1998, with 2,626 residents responding. (Of 4,832 sampled, 813 had invalid addresses or were no longer in the residency program. Among the valid sample of 4,019, the response rate was 65%.) The percentage of residents ranking public hospitals, rural areas, and poor inner-city areas as desirable employment locations and the percentage feeling prepared to provide specified services associated with indigent populations were ascertained. Logistic regressions were used to calculate adjusted percentages, controlling for sex, race/ethnicity, international medical graduate (IMG) status, plans to subspecialize, ownership of hospital, specialty, and exposure to underserved patients during residency. Only one third of residents rated public hospitals as desirable settings, although there were large variations by specialty. Desirability was not associated with having trained in a public hospital or having greater exposure to underserved populations. Only about one quarter of respondents ranked rural (26%) or poor inner-city (25%) areas as desirable. Men (29%, P <.01) and noncitizen IMGs (43%, P <.01) were more likely than others to prefer rural settings. Residents who were more likely to rate poor inner-city settings as desirable included women (28%, P =.03), noncitizen IMGs (35%, P =.01), and especially underrepresented minorities (52%, P <.01). Whereas about 90% or more of residents felt prepared to treat common clinical conditions, only 67% of residents in four primary care specialties felt prepared to counsel patients about domestic violence or to care for human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) or substance abuse patients (all 67%). Women were more likely than men to feel prepared to counsel patients about domestic violence (70% vs. 63%, P =.002) and depression (83% vs. 75%, P <.01). Underrepresented minority residents were more likely than other residents to feel prepared to counsel patients about domestic violence (P <.01) and compliance with care (P =.04). Residents with greater exposure to underserved groups were more prepared to counsel patients about domestic violence (P =.01), substance abuse (P =.01), and to treat patients with HIV/AIDS (P =.01) or with substance abuse problems (P <.01). This study demonstrates the need to expose graduate trainees to underserved populations and suggests a continuing role of minorities, women, and noncitizen physicians in caring for low-income populations.

International and US medical graduates in US cities

OBJECTIVES

This study examines the comparative distributions of postresident international medical graduates (IMGs) and US medical graduates (USMGs) in high and low poverty areas of US cities. Existing research has established that IMGs are more likely than USMGs to practice in urban areas, yet there is the question whether IMGs locate more frequently than USMGs in urban poverty areas.

METHODS

Data from the 1997 AMA Physician Masterfile and 1990 US Census were merged to classify physicians' practices into low- and high-poverty areas in selected cities.

RESULTS

In 14 cities with populations of 2.5 million or more, IMGs were located in a statistically significant disproportion in poverty areas of 7 cities. Of 36 cities with populations of 1,000,000 to 2,499,999, there were 5 cities that had significant IMG disproportions in poverty areas. Of a random sample of 27 cities with populations of 250,000 to 999,999, there were 2 cities that had significant IMG disproportions. Many cities in all three size categories had a large proportionate IMG complement of the total physician workforce located within high-poverty areas.

CONCLUSIONS

IMGs were found in disproportionate numbers in poverty areas in a number of US cities, especially the very largest ones. These findings are discussed in light of the current debate about a physician surplus and initiatives to reduce the number of IMGs in residency training.