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

Declining Rate of International Medical Graduates Matching Into Orthopedic Surgery Residency Programs in the United States: A 17-Year Analysis

Introduction

International medical graduates (IMGs) continue to play an important role in the US health care system, but little is known about their trends of matching into highly competitive residencies such as orthopedic surgery. The purpose of this study was to analyze temporal trends of IMG applicants matching into US orthopedic residency programs between 2008 and 2024 and compare them with US allopathic (MD) and osteopathic (DO) graduates.

Methods

Orthopedic residency specific data for years 2008 to 2024 was obtained from the National Resident Match Program and Electronic Residency Application Service. Variables collected included total number of programs, total positions offered, number of applicants (MD, DO, and IMG), positions filled, and fill rate for each group. Trends were examined using simple linear regression modeling.

Results

The number of orthopedic residency programs increased from 160 (2008) to 218 (2024), with total positions increasing from 636 (2008) to 916 (2024). The IMG fill rate decreased from 2.99% in 2008 to 0.87% in 2024 (p < 0.01 for linear trend; β -0.069). This corresponds to an absolute number decrease of 19 IMGs in 2008 to 8 in 2024. More specifically, the proportion of US IMGs decreased from 0.94% to 0.66%, and the proportion of non-US IMGs decreased from 2.04% to 0.21%. Over the 17-year study period, a total of 105 US IMGs and 110 non-US IMGs matched into orthopedic surgery. The US MD applicant fill rate decreased significantly from 96.5% to 85.0% (p < 0.001; β -0.944). The DO applicant fill rate increased significantly from 0.31% to 13.97% (p < 0.0001; β 0.990).

Conclusion

The declining rate of IMGs matching into orthopedic residency programs in the United States underscores the growing challenges faced by IMGs in accessing training in this competitive specialty. The notable increase in DO graduates securing orthopedic residency positions likely reflects the integration of a unified accreditation system for MD and DO residency programs established in 2020.

Level of Evidence

Retrospective Cohort Study; IV.

Brain drain in pediatric anesthesiology: The geographic and demographic distribution of national origin among pediatric anesthesiologists in the United States

BACKGROUND

American pediatric anesthesiologists have a long history of international volunteerism. However, the US healthcare system also benefits from the contributions of a large number of physicians who come from other nations to work within its borders. Despite this fact, little is known about the contribution of international medical graduates (IMG) to the pediatric anesthesiology subspecialty.

AIMS

To characterize the contribution of IMG to the field of pediatric anesthesiology in the United States, and to elucidate the geographic and demographic distribution of their national origins so as to understand the movement of skilled personnel between countries.

METHODS

Online physician directories of American children's hospitals were searched, and anesthesiologists were recorded for their national origin of medical education. International graduates were reported as a percentage of the pediatric anesthesiology workforce. Those attending medical colleges catering to American students ("offshore" medical schools) were analyzed separately from other IMGs. The cohort of non-offshore IMGs were analyzed for national and continental origins, and by national level of economic development.

RESULTS

Of 1979 anesthesiologists analyzed, 397 attended medical school outside the United States, with 58 being from offshore schools. The remaining 338 represented 17.1% of the total pediatric anesthesiology workforce. They came from 58 countries on six continents. Of those, 65.1% attended medical school in low- and middle-income countries.

CONCLUSIONS

International medical graduates, disproportionately from low- and middle-income countries, compose a large proportion of the US Pediatric Anesthesiology workforce. While these clinicians play a vital role in providing care for American children, the potential impacts of skilled physician loss on their nations of origin must also be considered.

International Medical Graduates in Radiology Residencies: Demographics, Performance, and Visa Issues

RATIONALE AND OBJECTIVES

The number of international medical graduates (IMG) in radiology residencies has varied from year to year even as the number of candidates continues to grow. It is unclear from which countries the IMGs are arriving and what visas are being used to accommodate them.

MATERIALS AND METHODS

We sent a survey to 195 program directors (PD) in diagnostic radiology (DR) inquiring about the number and nationality of IMG residents in their program, their attitudes about IMG candidates, the performance of their IMG trainees, and the visas that are offered.

RESULTS

We received responses from 121 of 195 (62.1%) DR programs (121/149 =81.2% of actionable emails). 80/121 (66.1%) had at least one IMG in their DR residency program and the countries of origin included India (36), Iran (30), Saudi Arabia (24), Egypt (16), Canada (14), Brazil (14), and Pakistan (9), as the most common. While most programs (76/104, 73.1%) offered J1 visas, 23/99 (23.2%) provided H-1B visas to trainees. IMG DR residents overall performed as well as American graduates, with an equal number of PDs saying IMGs performed better and worse than American graduates. PDs' issues with IMGs centered on visas: (1) expense, (2) lack of familiarity, (3) Educational Commission for Foreign Medical Graduates regulations, and (4) time commitment in submitting paperwork.

CONCLUSION

Most radiology IMG residents originate from India and Middle Eastern countries. Once enrolled, IMG residents perform similarly to US graduates. However, adding IMG candidates to the training program requires overcoming bureaucratic and monetary hurdles around visas.

SUMMARY SENTENCE

Most DR international medical graduate residents are from India or the Middle East. Although their performance is the same as American graduates in general, PDs note the monetary and bureaucratic hassles accompanying their recruitment.

Reported Visa Acceptance or Sponsorship for Non-US Citizen Applicants to US Internal Medicine Residency Programs

BACKGROUND

Non-US citizen international medical graduates (IMGs) make up a significant proportion of the physician workforce, especially in physician shortage areas and specialties. IMGs face barriers matriculating in US residency programs. Whether a program reports accepting J-1 visas and sponsoring H-1B visas influences their decision to apply, it remains unclear which institutional factors shape programs' likelihood to consider visa-seeking applicants.

OBJECTIVE

We investigated factors associated with programs reporting accepting J-1 visas or sponsoring H-1B visas for non-citizen applicants in internal medicine, the specialty most sought after by IMGs.

METHODS

We performed multivariable regression analyses using publicly available data to identify characteristics associated with reported visa acceptance (J-1 and or H-1B). Covariates included university affiliation, program size, program type (academic, university-affiliated community, or community), and Doximity reputation ranking.

RESULTS

We identified 419 programs: 267 (63.7%) reported accepting J-1 visas. Among programs that accepted J-1 visas, 65.6% (n=175) accepted only J-1 visas while 34.5% (n=92) sponsored H-1B and accepted J-1 visas. Ranking in the third quartile (vs first quartile) was associated with lower odds of accepting J-1 (aOR 0.12; 95% CI 0.02-0.87; P=.04) and sponsoring H-1B visas (aOR 0.19; 95% CI 0.05-0.76; P=.02). Community status (vs academic) was associated with lower odds of accepting J-1 visas (aOR 0.2; 95% CI 0.06-0.64; P=.007), as was county hospital affiliation vs non-county hospitals (aOR 0.22; 95% CI 0.11-0.42; P<.001).

CONCLUSIONS

While prior evidence shows that most internal medicine programs that substantially enroll IMGs are low ranking, high-ranking internal medicine programs are paradoxically more likely to report that they consider and sponsor visa-seeking applicants.

Using State All-Payer Claims Data to Identify the Active Primary Care Workforce: A Novel Study in Virginia

PURPOSE

Primary care is the foundation of the health care workforce and the only part that extends life and improves health equity. Previous research on the geographic and specialty distribution of physicians has relied on the American Medical Association's Masterfile, but these data have limitations that overestimate the workforce.

METHODS

We present a pragmatic, systematic, and more accurate method for identifying primary care physicians using the National Plan and Provider Enumeration System (NPPES) and the Virginia All-Payer Claims Database (VA-APCD). Between 2015 and 2019, we identified all Virginia physicians and their specialty through the NPPES. Active physicians were defined by at least 1 claim in the VA-APCD. Specialty was determined hierarchically by the NPPES. Wellness visits were used to identify non-family medicine physicians who were providing primary care.

RESULTS

In 2019, there were 20,976 active physicians in Virginia, of whom 5,899 (28.1%) were classified as providing primary care. Of this primary care physician workforce, 52.4% were family medicine physicians; the remaining were internal medicine physicians (18.5%), pediatricians (16.8%), obstetricians and gynecologists (11.8%), and other specialists (0.5%). Over 5 years, the counts and relative percentages of the workforce made up by primary care physicians remained relatively stable.

CONCLUSIONS

Our novel method of identifying active physicians with a primary care scope provides a realistic size of the primary care workforce in Virginia, smaller than some previous estimates. Although the method should be expanded to include advanced practice clinicians and to further delineate the scope of practice, this simple approach can be used by policy makers, payers, and planners to ensure adequate primary care capacity.

International Medical Graduates in the United States Psychiatry Workforce

OBJECTIVE

This study describes the supply, distribution, and characteristics of international medical graduate (IMG) psychiatrists who provide services in the USA.

METHODS

Cross-sectional study design, using descriptive statistics based on combined data from the American Medical Association (2020 Physician Masterfile) and the Educational Commission for Foreign Medical Graduates.

RESULTS

International medical graduates continue to make significant contributions to the US physician workforce. As a group, they represent 29% of active psychiatrists in the USA, compared to 23% in all other medical specialties. Many IMG psychiatrists were US citizens who obtained their medical degrees outside the USA or Canada, often in the Caribbean. In some states (i.e., Florida, New Jersey), over 40% of active psychiatrists are IMGs. Over 30% of IMG psychiatrists graduated from medical schools in India and Pakistan.

CONCLUSIONS

This study provides an overview of the psychiatric workforce in the USA, quantifying the specific contribution of IMGs. Several factors, including immigration policies, continued expansion of US medical schools, and the number of available residency positions, could impact the flow of IMGs to the US. Longitudinal studies are needed to better understand the implications for workforce composition and distribution, and their potential impact on the care of psychiatric patients.

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.

Veterinary Practice - The Canadian multinational veterinary workforce

The veterinary profession, from acceptance to veterinary college to retirement, has experienced extensive organizational change in the past 3 decades. This paper is an attempt to understand the context and complexity of national workforce planning in veterinary medicine in Canada. It identifies the obvious practical and ethical considerations, exposing inherent problems in guiding the future of the profession. The discourse concludes there is a structural deficiency in veterinary education program capacity in Canada (practical fact) and Canadian youth may have increasingly difficult access to tertiary education (ethical concern). Adaptation, rather than planning, characterizes current practices in which migration of foreign-trained veterinarians mitigates the structural deficiency in training capacity. Due to the pervasive adoption of neo-liberal marketing principles in tertiary education, a nationally self-sufficient Canadian veterinary college infrastructure is an unlikely future possibility. Our current system, reliant on migration of internationally trained professionals, raises questions of global justice and individual rights. Strategic solutions require reflection on veterinary professional identity, broad discussion, and a commitment to a rigorous concept of professional responsibilities, global citizenship, and the public good.

International Medical Graduates in the Pediatric Workforce in the United States

BACKGROUND AND OBJECTIVES

To describe the supply, distribution, and characteristics of international medical graduates (IMGs) in pediatrics who provide patient care in the United States.

METHODS

Cross-sectional study, combining data from the 2019 Physician Masterfile of the American Medical Association and the Educational Commission for Foreign Medical Graduates database.

RESULTS

In total, 92 806 pediatric physicians were identified, comprising 9.4% of the entire US physician workforce. Over half are general pediatricians. IMGs account for 23.2% of all general pediatricians and pediatric subspecialists. Of all IMGs in pediatrics, 22.1% or 4775 are US citizens who obtained their medical degree outside the United States or Canada, and 15.4% (3246) attended medical school in the Caribbean. Fifteen non-US medical schools account for 29.9% of IMGs currently in active practice in pediatrics in the United States. IMGs are less likely to work in group practice or hospital-based practice and are more likely to be employed in solo practice (compared with US medical school graduates).

CONCLUSIONS

With this study, we provide an overview of the pediatric workforce, quantifying the contribution of IMGs. Many IMGs are US citizens who attend medical school abroad and return to the United States for postgraduate training. Several factors, including the number of residency training positions, could affect future numbers of IMGs entering the United States. Longitudinal studies are needed to better understand the implications that workforce composition and distribution may have for the care of pediatric patients.

Prevalence of International Medical Graduates From Muslim-Majority Nations in the US Physician Workforce From 2009 to 2019

IMPORTANCE

Historically, the US physician workforce has included a large number of international medical graduates (IMGs). Recent US immigration policies may affect the inflow of IMGs, particularly those who are citizens of Muslim-majority nations.

OBJECTIVES

To provide an overview of the characteristics of IMGs from Muslim-majority nations, including their contributions to the US physician workforce, and to describe trends in the number of applications for certification to the Educational Commission for Foreign Medical Graduates between 2019 and 2018, both overall and for citizens of Muslim-majority nations.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study, which included 1 065 606 US physicians listed in the 2019 American Medical Association Physician Masterfile and 156 017 applicants to the Educational Commission for Foreign Medical Graduates certification process between 2009 and 2018, used a repeated cross-sectional study design to review the available data, including country of medical school attended, citizenship when entering medical school, and career information, such as present employment, specialty, and type of practice.

EXPOSURES

Country of citizenship when entering medical school.

MAIN OUTCOMES AND MEASURES

Physician counts and demographic information from the 2019 American Medical Association Physician Masterfile and applicant data from the Educational Commission for Foreign Medical Graduates from 2009 to 2018.

RESULTS

Of 1 065 606 physicians in the American Medical Association Physician Masterfile, 263 029 (24.7%) were IMGs, of whom 48 354 were citizens of Muslim-majority countries at time of entry to medical school, representing 18.4% of all IMGs. Overall, 1 in 22 physicians in the US was an IMG from a Muslim-majority nation, representing 4.5% of the total US physician workforce. More than half of IMGs from Muslim-majority nations (24 491 [50.6%]) come from 3 countries: Pakistan (14 352 [29.7%]), Iran (5288 [10.9%]), and Egypt (4851 [10.0%]). The most prevalent specialties include internal medicine (10 934 [23.6%]), family medicine (3430 [7.5%]), pediatrics (2767 [5.9%]), and psychiatry (2251 [4.8%]), with 18 229 (38.1%) practicing in primary care specialties. The number of applicants for Educational Commission for Foreign Medical Graduates certification from Muslim-majority countries increased from 2009 (3227 applicants) to 2015 (4244 applicants), then decreased by 2.1% in 2016 to 4254 applicants, 4.3% in 2017 to 4073 applicants, and 11.5% in 2018 to 3604 applicants. Much of this decrease could be attributed to fewer citizens from Pakistan (1042 applicants in 2015 to 919 applicants in 2018), Egypt (493 applicants in 2015 to 309 applicants in 2018), Iran (281 applicants in 2015 to 182 applicants in 2018), and Saudi Arabia (337 applicants in 2015 to 163 applicants in 2018) applying for certification.

CONCLUSIONS AND RELEVANCE

Based on the findings of this study, the number of ECFMG applicants from Muslim-majority countries decreased from 2015 to 2018. The US physician workforce will continue to rely on IMGs for some time to come. To the extent that citizens from some countries no longer seek residency positions in the US, gaps in the physician workforce could widen.