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1.  Examination outcomes for international medical graduates pursuing or completing family medicine residency training in Quebec 
Canadian Family Physician  2010;56(9):912-918.
ABSTRACT
OBJECTIVE
To review the success of international medical graduates (IMGs) who are pursuing or have completed a Quebec residency training program and examinations.
DESIGN
We retrospectively reviewed IMGs’ success rates on the pre-residency Collège des médecins du Québec medical clinical sciences written examination and objective structured clinical examination, as well as on the post-residency Certification Examination in Family Medicine.
SETTING
Quebec.
PARTICIPANTS
All IMGs taking their examinations between 2001 and 2008, inclusive, and Canadian and American graduates taking their examinations during this same period.
MAIN OUTCOME MEASURES
Success rates for IMGs on the pre-residency and post-residency examinations, compared with success rates for Canadian and American graduates.
RESULTS
Success rates on the pre-residency clinical examinations remained below 50% from 2001 to 2008 for IMGs. Similarly, during the same period, the average success rate on the Certification examination was 56.0% for IMGs, compared with 93.5% for Canadian and American medical graduates.
CONCLUSION
Despite pre-residency competency screening and in-program orientation and supports, a substantial number of IMGs in Quebec are not passing their Certification examinations. Another study is under way to analyze reasons for some IMGs’ lack of success and to find ways to help IMGs complete residency training successfully and pass the Certification examination.
PMCID: PMC2939121  PMID: 20841596
2.  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.
doi:10.1186/1478-4491-4-17
PMCID: PMC1543651  PMID: 16848909
3.  How do IMGs compare with Canadian medical school graduates in a family practice residency program? 
Canadian Family Physician  2010;56(9):e318-e322.
ABSTRACT
OBJECTIVE
To compare international medical graduates (IMGs) with Canadian medical school graduates in a family practice residency program.
DESIGN
Analysis of the results of the in-training evaluation reports (ITERs) and the Certification in Family Medicine (CCFP) examination results for 2 cohorts of IMGs and Canadian-trained graduates between the years 2006 and 2008.
SETTING
St Paul’s Hospital (SPH) in Vancouver, BC, a training site of the University of British Columbia (UBC) Family Practice Residency Program.
PARTICIPANTS
In-training evaluation reports were examined for 12 first-year and 9 second-year Canadian-trained residents at the SPH site, and 12 first-year and 12 second-year IMG residents at the IMG site at SPH; CCFP examination results were reviewed for all UBC family practice residents who took the May 2008 examination and disclosed their results.
MAIN OUTCOME MEASURES
Pass or fail rates on the CCFP examination; proportions of evaluations in each group of residents given each of the following designations: exceeds expectations, meets expectations, or needs improvement. The May 2008 CCFP examination results were reviewed.
RESULTS
Compared with the second-year IMGs, the second-year SPH Canadian-trained residents had a greater proportion of exceeds expectations designations than the IMGs. For the first-year residents, both the SPH Canadian graduates and IMGs had similar results in all 3 categories. Combining the results of the 2 cohorts, the Canadian-trained residents had 310 (99%) ITERs that were designated as either exceeds expectations or meets expectations, and only 3 (1%) ITERs were in the needs improvement category. The IMG results were 362 (97.6%) ITERs in the exceeds expectations or meets expectations categories; 9 (2%) were in the needs improvement category. Statistically these are not significant differences. Seven of the 12 (58%) IMG candidates passed the CCFP examination compared with 59 of 62 (95%) of the UBC family practice residents.
CONCLUSION
The IMG residents compared favourably with their Canadian-trained colleagues when comparing ITERs but not in passing the CCFP examination. Further research is needed to elucidate these results.
PMCID: PMC2939132  PMID: 20841570
4.  International medical graduates (IMGs) needs assessment study: comparison between current IMG trainees and program directors 
Background
International Medical Graduates (IMGs) training within the Canadian medical education system face unique difficulties. The purpose of this study was to explore the challenges IMGs encounter from the perspective of trainees and their Program Directors.
Methods
Program Directors of residency programs and IMGs at the University of Toronto were anonymously surveyed and asked to rate (using a 5-point Likert scale; 1 = least important – 5 = most important) the extent to which specific issues were challenging to IMGs and whether an orientation program (in the form of a horizontal curriculum) should be implemented for incoming IMGs prior to starting their residency.
Results
Among the IMGs surveyed, Knowledge of the Canadian Healthcare System received the highest mean score (3.93), followed by Knowledge of Pharmaceuticals and Hospital formularies (3.69), and Knowledge of the Hospital System (3.69). In contrast, Program Directors felt that Communication with Patients (4.40) was a main challenge faced by IMGs, followed by Communication with Team Members (4.33) and Basic Clinical Skills (4.28).
Conclusion
IMGs and Program Directors differ in their perspectives as to what are considered challenges to foreign-trained physicians entering residency training. Both groups agree that an orientation program is necessary for incoming IMGs prior to starting their residency program.
doi:10.1186/1472-6920-8-42
PMCID: PMC2546389  PMID: 18759968
5.  Characteristics and practice patterns of international medical graduates 
Canadian Family Physician  2007;53(8):1330-1331.
OBJECTIVE
To investigate the personal characteristics and practice patterns of international medical graduates (IMGs) practising in southwestern Ontario and to compare them with the personal characteristics and practice patterns of Canadian-trained family physicians practising in the same region.
DESIGN
Cross-sectional analysis of data gathered from a census of family physicians.
SETTING
Southwestern Ontario.
PARTICIPANTS
A total of 685 family physicians.
MAIN OUTCOME MEASURES
Characteristics and practice patterns of IMG physicians and Canadian-trained physicians.
RESULTS
Among all family physicians practising in southwestern Ontario, 15.3% were IMGs. The IMGs were more likely than Canadian-trained medical graduates to be older and to have been in practice longer, and less likely to have completed a family medicine residency or to have been involved in undergraduate or postgraduate teaching. The IMGs were more likely to have practised longer in their current locations and to be in solo practice and accepting new patients, but were less likely to be providing maternity and newborn care. They were also more likely than Canadian-trained medical graduates were to be serving in small towns and rural and isolated communities.
CONCLUSION
The personal and practice characteristics of IMG physicians vary somewhat from those of their Canadian-trained colleagues. Policy efforts aimed at increasing and integrating IMG family physicians into the work force need to recognize these differences. Further research is needed before our results can be generalized to physicians practising beyond southwestern Ontario.
PMCID: PMC1949260  PMID: 17872850
6.  The research rotation: competency-based structured and novel approach to research training of internal medicine residents 
Background
In the United States, the Accreditation Council of graduate medical education (ACGME) requires all accredited Internal medicine residency training programs to facilitate resident scholarly activities. However, clinical experience and medical education still remain the main focus of graduate medical education in many Internal Medicine (IM) residency-training programs. Left to design the structure, process and outcome evaluation of the ACGME research requirement, residency-training programs are faced with numerous barriers. Many residency programs report having been cited by the ACGME residency review committee in IM for lack of scholarly activity by residents.
Methods
We would like to share our experience at Lincoln Hospital, an affiliate of Weill Medical College Cornell University New York, in designing and implementing a successful structured research curriculum based on ACGME competencies taught during a dedicated "research rotation".
Results
Since the inception of the research rotation in 2004, participation of our residents among scholarly activities has substantially increased. Our residents increasingly believe and appreciate that research is an integral component of residency training and essential for practice of medicine.
Conclusion
Internal medicine residents' outlook in research can be significantly improved using a research curriculum offered through a structured and dedicated research rotation. This is exemplified by the improvement noted in resident satisfaction, their participation in scholarly activities and resident research outcomes since the inception of the research rotation in our internal medicine training program.
doi:10.1186/1472-6920-6-52
PMCID: PMC1630691  PMID: 17044924
7.  Accreditation council for graduate medical education (ACGME) annual anesthesiology residency and fellowship program review: a "report card" model for continuous improvement 
BMC Medical Education  2010;10:13.
Background
The Accreditation Council for Graduate Medical Education (ACGME) requires an annual evaluation of all ACGME-accredited residency and fellowship programs to assess program quality. The results of this evaluation must be used to improve the program. This manuscript describes a metric to be used in conducting ACGME-mandated annual program review of ACGME-accredited anesthesiology residencies and fellowships.
Methods
A variety of metrics to assess anesthesiology residency and fellowship programs are identified by the authors through literature review and considered for use in constructing a program "report card."
Results
Metrics used to assess program quality include success in achieving American Board of Anesthesiology (ABA) certification, performance on the annual ABA/American Society of Anesthesiology In-Training Examination, performance on mock oral ABA certification examinations, trainee scholarly activities (publications and presentations), accreditation site visit and internal review results, ACGME and alumni survey results, National Resident Matching Program (NRMP) results, exit interview feedback, diversity data and extensive program/rotation/faculty/curriculum evaluations by trainees and faculty. The results are used to construct a "report card" that provides a high-level review of program performance and can be used in a continuous quality improvement process.
Conclusions
An annual program review is required to assess all ACGME-accredited residency and fellowship programs to monitor and improve program quality. We describe an annual review process based on metrics that can be used to focus attention on areas for improvement and track program performance year-to-year. A "report card" format is described as a high-level tool to track educational outcomes.
doi:10.1186/1472-6920-10-13
PMCID: PMC2830223  PMID: 20141641
8.  Global health opportunities within pediatric subspecialty fellowship training programs: surveying the virtual landscape 
BMC Medical Education  2013;13:88.
Background
There is growing interest in global health among medical trainees. Medical schools and residencies are responding to this trend by offering global health opportunities within their programs. Among United States (US) graduating pediatric residents, 40% choose to subspecialize after residency training. There is limited data, however, regarding global health opportunities within traditional post-residency, subspecialty fellowship training programs. The objectives of this study were to explore the availability and type of global health opportunities within Accreditation Council for Graduate Medical Education (ACGME)-accredited pediatric subspecialty fellowship training programs, as noted by their online report, and to document change in these opportunities over time.
Methods
The authors performed a systematic online review of ACGME-accredited fellowship training programs within a convenience sample of six US pediatric subspecialties. Utilizing two data sources, the American Medical Association-Fellowship and Residency Electronic Interactive Database Access (AMA-FREIDA) and individual program websites, all programs were coded for global health opportunities and opportunity types were stratified into predefined categories. Comparisons were made between 2008 and 2011 using Fisher exact test. All analyses were conducted using SAS Software v. 9.3 (SAS Institute Inc., Cary, NC).
Results
Of the 355 and 360 programs reviewed in 2008 and 2011 respectively, there was an increase in total number of programs listing global health opportunities on AMA-FREIDA (16% to 23%, p=0.02) and on individual program websites (8% to 16%, p=0.004). Nearly all subspecialties had an increased percentage of programs offering global health opportunities on both data sources; although only critical care experienced a significant increase (p=0.04, AMA-FREIDA). The types of opportunities differed across all subspecialties.
Conclusions
Global health opportunities among ACGME-accredited pediatric subspecialty fellowship programs are limited, but increasing as noted by their online report. The availability and types of these opportunities differ by pediatric subspecialty.
doi:10.1186/1472-6920-13-88
PMCID: PMC3691626  PMID: 23787005
Global health; Pediatrics; Graduate medical education; Subspecialty; Fellowship training
9.  Predictors of Final Specialty Choice by Internal Medicine Residents 
Journal of General Internal Medicine  2006;21(10):1045-1049.
BACKGROUND
Sociodemographic factors and personality attributes predict career decisions in medical students. Determinants of internal medicine residents' specialty choices have received little attention.
OBJECTIVE
To identify factors that predict the clinical practice of residents following their training.
DESIGN
Prospective cohort study.
PARTICIPANTS
Two hundred and four categorical residents from 2 university-based residency programs.
MEASUREMENTS
Sociodemographic and personality inventories performed during residency, and actual careers 4 to 9 years later.
RESULTS
International medical school graduates (IMGs) were less likely to practice general medicine than U.S. graduates (33.3% vs 70.6%, P<.001). Residents with higher loan indebtedness more often became generalists (P = .001). A corresponding trend favoring general internal medicine was observed among those who perceived General Internists to have lower potential incomes (69.0% vs 53.3%, P = .08). There was a trend for generalists to have lower scores on scales measuring authoritarianism, negative orientation to psychological problems, and Machiavellianism (0.05
CONCLUSION
Recruitment of IMGs may not increase the supply of General Internists. Prospects of lower income, even in the face of large debt, may not discourage residents from becoming generalists. If increasing generalist manpower is a goal, residencies should consider weighing applicants' personal attributes during the selection process.
doi:10.1111/j.1525-1497.2006.00556.x
PMCID: PMC1831640  PMID: 16836624
career choice; general internal medicine; health manpower; international medical graduates
BMC Medical Education  2011;11:30.
Background
Several residency program characteristics have been suggested as measures of program quality, but associations between these measures are unknown. We set out to determine associations between these potential measures of program quality.
Methods
Survey of internal medicine residency programs that shared an online ambulatory curriculum on hospital type, faculty size, number of trainees, proportion of international medical graduate (IMG) trainees, Internal Medicine In-Training Examination (IM-ITE) scores, three-year American Board of Internal Medicine Certifying Examination (ABIM-CE) first-try pass rates, Residency Review Committee-Internal Medicine (RRC-IM) certification length, program director clinical duties, and use of pharmaceutical funding to support education. Associations assessed using Chi-square, Spearman rank correlation, univariate and multivariable linear regression.
Results
Fifty one of 67 programs responded (response rate 76.1%), including 29 (56.9%) community teaching and 17 (33.3%) university hospitals, with a mean of 68 trainees and 101 faculty. Forty four percent of trainees were IMGs. The average post-graduate year (PGY)-2 IM-ITE raw score was 63.1, which was 66.8 for PGY3s. Average 3-year ABIM-CE pass rate was 95.8%; average RRC-IM certification was 4.3 years. ABIM-CE results, IM-ITE results, and length of RRC-IM certification were strongly associated with each other (p < 0.05). PGY3 IM-ITE scores were higher in programs with more IMGs and in programs that accepted pharmaceutical support (p < 0.05). RRC-IM certification was shorter in programs with higher numbers of IMGs. In multivariable analysis, a higher proportion of IMGs was associated with 1.17 years shorter RRC accreditation.
Conclusions
Associations between quality indicators are complex, but suggest that the presence of IMGs is associated with better performance on standardized tests but decreased duration of RRC-IM certification.
doi:10.1186/1472-6920-11-30
PMCID: PMC3126786  PMID: 21651768
program quality; Residency Review Committee; American Board of Internal Medicine Certifying Examination
Academic Medicine  2011;86(11):1383-1388.
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.
doi:10.1097/ACM.0b013e31823035e1
PMCID: PMC3257160  PMID: 21952056
Health Services Research  2002;37(4):907-928.
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.
doi:10.1034/j.1600-0560.2002.58.x
PMCID: PMC1464010  PMID: 12236390
Physicians; international medical graduates; health economics; physician labor markets; ethnic matching
Background
Increased focus on the number and type of physicians delivering health care in the United States necessitates a better understanding of changes in graduate medical education (GME). Data collected by the Accreditation Council for Graduate Medical Education (ACGME) allow longitudinal tracking of residents, revealing the number and type of residents who continue GME following completion of an initial residency. We examined trends in the percent of graduates pursuing additional clinical education following graduation from ACGME-accredited pipeline specialty programs (specialties leading to initial board certification).
Methods
Using data collected annually by the ACGME, we tracked residents graduating from ACGME-accredited pipeline specialty programs between academic year (AY) 2002–2003 and AY 2006–2007 and those pursuing additional ACGME-accredited training within 2 years. We examined changes in the number of graduates and the percent of graduates continuing GME by specialty, by type of medical school, and overall.
Results
The number of pipeline specialty graduates increased by 1171 (5.3%) between AY 2002–2003 and AY 2006–2007. During the same period, the number of graduates pursuing additional GME increased by 1059 (16.7%). The overall rate of continuing GME increased each year, from 28.5% (6331/22229) in AY 2002–2003 to 31.6% (7390/23400) in AY 2006–2007. Rates differed by specialty and for US medical school graduates (26.4% [3896/14752] in AY 2002–2003 to 31.6% [4718/14941] in AY 2006–2007) versus international medical graduates (35.2% [2118/6023] to 33.8% [2246/6647]).
Conclusion
The number of graduates and the rate of continuing GME increased from AY 2002–2003 to AY 2006–2007. Our findings show a recent increase in the rate of continued training for US medical school graduates compared to international medical graduates. Our results differ from previously reported rates of subspecialization in the literature. Tracking individual residents through residency and fellowship programs provides a better understanding of residents' pathways to practice.
doi:10.4300/JGME-D-10-00105.1
PMCID: PMC3010950  PMID: 22132288
Background
International medical graduates (IMGs) have been a valuable resource for the United States physician workforce, and their contribution to the United States workforce is likely to increase.
Objective
To describe the historical trends and compare the characteristics of IMGs to United States medical graduates (USMGs) in the United States.
Design
Longitudinal analysis of the American Medical Association Physicians’ Professional Data (AMA-PPD) database using the 1978–2004 files and a comparative analysis of the characteristics of a random sample of 1,000 IMGs and a random sample of 1,000 USMGs using the 2004 file.
Measurements
Historical trends and characteristics of IMGs in the United States.
Results
Over the last 26 years, the number of IMGs in the United States grew by 4,873 per year reaching a total of 215,576 in 2004, about 2.4 times its size in 1978. The proportion of IMGs increased 0.12% per year, from 22.2% in 1978 to 25.6% in 2004. In 2004, compared with USMGs, IMGs were older, less likely to be board certified [Odds ratio (OR), 0.68; 95% CI, 0.53 to 0.86], less likely to work in group practice (OR, 0.60; 95% CI, 0.37 to 0.98), more likely to have Internal Medicine as practice specialty (OR, 2.10; 95% CI, 1.62 to 2.71) and more likely to be residents (OR, 1.52; 95% CI, 1.07 to 2.16).
Conclusions
Over the last quarter century, the IMGs provided a significant and steady supply for the United States physician workforce that continues to grow. Policymakers should consider the consequences for both the United States and source countries.
doi:10.1007/s11606-006-0022-2
PMCID: PMC1824721  PMID: 17356997
foreign medical graduates; health manpower; internship and residency
Background
International medical graduates (IMGs) have been a valuable resource for the United States physician workforce, and their contribution to the United States workforce is likely to increase.
Objective
To describe the historical trends and compare the characteristics of IMGs to United States medical graduates (USMGs) in the United States.
Design
Longitudinal analysis of the American Medical Association Physicians’ Professional Data (AMA-PPD) database using the 1978–2004 files and a comparative analysis of the characteristics of a random sample of 1,000 IMGs and a random sample of 1,000 USMGs using the 2004 file.
Measurements
Historical trends and characteristics of IMGs in the United States.
Results
Over the last 26 years, the number of IMGs in the United States grew by 4,873 per year reaching a total of 215,576 in 2004, about 2.4 times its size in 1978. The proportion of IMGs increased 0.12% per year, from 22.2% in 1978 to 25.6% in 2004. In 2004, compared with USMGs, IMGs were older, less likely to be board certified [Odds ratio (OR), 0.68; 95% CI, 0.53 to 0.86], less likely to work in group practice (OR, 0.60; 95% CI, 0.37 to 0.98), more likely to have Internal Medicine as practice specialty (OR, 2.10; 95% CI, 1.62 to 2.71) and more likely to be residents (OR, 1.52; 95% CI, 1.07 to 2.16).
Conclusions
Over the last quarter century, the IMGs provided a significant and steady supply for the United States physician workforce that continues to grow. Policymakers should consider the consequences for both the United States and source countries.
doi:10.1007/s11606-006-0022-2
PMCID: PMC1824721  PMID: 17356997
foreign medical graduates; health manpower; internship and residency
Background
International medical graduates (IMGs) comprise approximately 25% of the US physician workforce, with significant representation in primary care and care of vulnerable populations. Despite the central role of IMGs in the US healthcare system, understanding of their professional experiences is limited.
Objective
To characterize the professional experiences of non-US born IMGs from limited-resource nations practicing primary care in the US.
Design
Qualitative study based on in-depth in-person interviews.
Participants
Purposeful sample of IMGs (n = 25) diverse in country of origin, length of practice in the US, specialty (internal medicine, family medicine and pediatrics), age and gender. Participants were currently practicing primary care physicians in New York, New Jersey or Connecticut.
Approach
A standardized interview guide was used to explore professional experiences of IMGs.
Key Results
Four recurrent and unifying themes characterize these experiences: 1) IMGs experience both overt and subtle forms of workplace bias and discrimination; 2) IMGs recognize professional limitations as part of “the deal”; 3) IMGs describe challenges in the transition to the culture and practice of medicine in the US; 4) IMGs bring unique skills and advantages to the workplace.
Conclusions
Our data reveal that IMGs face workplace challenges throughout their careers. Despite diversity in professional background and demographic characteristics, IMGs in our study reported common experiences in the transition to and practice of medicine in the US. Findings suggest that both workforce and workplace interventions are needed to enable IMG physicians to sustain their essential and growing role in the US healthcare system. Finally, commonalities with experiences of other minority groups within the US healthcare system suggest that optimizing IMGs’ experiences may also improve the experiences of an increasingly diverse healthcare workforce.
doi:10.1007/s11606-010-1401-2
PMCID: PMC2917670  PMID: 20502974
primary care; qualitative research; workforce; international medical graduates
Background:
Since 2002, market studies have predicted a physician shortage with an increasing need for future subspecialists. A Residency Review Committee (RRC) rule that restricted sponsorship of fellowships was eliminated in 2005, but the influence of this change on the number of fellowships is not known. We believed that the rules change might make it possible for community hospitals to offer fellowships. Our objectives were to determine the extent of change in the number of fellowships in university and community hospitals from 2000 through 2008, both before and after the RRC regulation change in 2005, and to determine whether community hospitals contributed substantially to the number of new fellowships available to internal medicine graduates.
Methods:
We used archived Accreditation Council for Graduate Medical Education (ACGME) data from July 2000 through June 2008. The community hospital category included multispecialty clinics, community programs, and municipal hospitals.
Results:
Of the 94 newly approved internal medicine subspecialty fellowships in this time period, 59 (63%) were community sponsored. As of 6/02/08, all were in good standing. Thirteen programs were started as a department of medicine solo fellowship since 2005. The number of new programs approved between 2005 and 2008 was roughly three times the number approved between 2000 and 2004.
Conclusions:
The number of subspecialty fellowship programs and approved positions has increased dramatically in the last 8 years. Many of the new programs were at community hospitals. The change in RRC rules has been associated with increased availability of fellowship programs in the university and community hospital setting for subspecialty training.
doi:10.3885/meo.2009.Res00307
PMCID: PMC2779615  PMID: 20165522
Specialists; workforce; supply
OBJECTIVE: This study reports on career intentions of U.S medical graduate (USMG) and international medical graduate (IMG) residents who completed residency training from 2000 to 2003 in California. METHODS: A retrospective study of 3178 responses to the Survey of Residents Completing Training in California. RESULTS: USMGs were 86% and 14% were IMGs. IMG holders of temporary visas had the highest obligation to serve in health professional shortage areas (HPSA) and were also the most likely to serve in HPSAs (p = 0.012). Underserved residency program location (OR = 2.7, p = 0.000), HPSA obligation (OR = 5.93, p = 0.001) and postresidency training (OR = 0.561, p = 0.048) were independently predictive of practice in underserved location, HPSA or public hospital. In addition, underrepresented minorities, primary care specialty and income were independently predictive of HPSA practice. CONCLUSION: In California, HPSA obligation, residency training programs characteristics and underrepresented minorities are important predictors of residents choosing to work in underserved areas.
PMCID: PMC2574406  PMID: 17987917
BMC Medical Education  2012;12:94.
Background
The American Board of Internal Medicine Certification Examination (ABIM-CE) is one of several methods used to assess medical knowledge, an Accreditation Council for Graduate Medical Education (ACGME) core competency for graduating internal medicine residents. With recent changes in graduate medical education program directors and internal medicine residents are seeking evidence to guide decisions regarding residency elective choices. Prior studies have shown that formalized elective curricula improve subspecialty ABIM-CE scores. The primary aim of this study was to evaluate whether the number of subspecialty elective exposures or the specific subspecialties which residents complete electives in impact ABIM-CE scores.
Methods
ABIM-CE scores, elective exposures and demographic characteristics were collected for MedStar Georgetown University Hospital internal medicine residents who were first-time takers of the ABIM-CE in 2006–2010 (n=152). Elective exposures were defined as a two-week period assigned to the respective subspecialty. ABIM-CE score was analyzed using the difference between the ABIM-CE score and the standardized passing score (delta-SPS). Subspecialty scores were analyzed using percentage of correct responses. Data was analyzed using GraphPad Prism version 5.00 for Windows.
Results
Paired elective exposure and ABIM-CE scores were available in 131 residents. There was no linear correlation between ABIM-CE mean delta-SPS and the total number of electives or the number of unique elective exposures. Residents with ≤14 elective exposures had higher ABIM-CE mean delta-SPS than those with ≥15 elective exposures (143.4 compared to 129.7, p=0.051). Repeated electives in individual subspecialties were not associated with significant difference in mean ABIM-CE delta-SPS.
Conclusions
This study did not demonstrate significant positive associations between individual subspecialty elective exposures and ABIM-CE mean delta-SPS score. Residents with ≤14 elective exposures had higher ABIM-CE mean delta-SPS than those with ≥15 elective exposures suggesting there may be an “ideal” number of elective exposures that supports improved ABIM-CE performance. Repeated elective exposures in an individual specialty did not correlate with overall or subspecialty ABIM-CE performance.
doi:10.1186/1472-6920-12-94
PMCID: PMC3480921  PMID: 23057635
Resident education; Gender; Elective; Subspecialty; Graduate medical education
Canadian Family Physician  2012;58(6):662-667.
Abstract
Objective
To identify factors that help predict success for international medical graduates (IMGs) who train in Canadian residency programs and pass the Canadian certification examinations.
Design
A retrospective analysis of 58 variables in the files of IMGs who applied to the Collège des médecins du Québec between 2000 and 2008.
Setting
Quebec.
Participants
Eight hundred ten IMGs who applied to the Collège des médecins du Québec through either the “equivalency pathway” (ie, starting training at a residency level) or the “clerkship pathway” (ie, relearning at the level of a medical student in the last 2 years of the MD diploma).
Main outcome measures
Success factors in achieving certification. Data were analyzed using descriptive statistics and ANOVA (analysis of variance).
Results
International medical graduates who chose the “clerkship pathway” had greater success on certification examinations than those who started at the residency level did.
Conclusion
There are several factors that influence IMGs’ success on certification examinations, including integration issues, the acquisition of clinical decision-making skills, and the varied educational backgrounds. These factors perhaps can be better addressed by a regular clerkship pathway, in which IMGs benefit from learner-centred teaching and have more time for reflection on and understanding of the North American approach to medical education. The clerkship pathway is a useful strategy for assuring the integration of IMGs in the North American health care system. A 2-year relearning period in medical school at a clinical clerkship level deserves careful consideration.
PMCID: PMC3374691  PMID: 22859630
Healthcare Policy  2007;3(2):50-57.
We linked the Memorial University of Newfoundland (MUN) postgraduate database with Scott's Medical Database to determine 2004 work locations of physicians who started residency training at MUN by 1998 to assess whether international medical graduates (IMGs) are as likely as MUN and other Canadian medical graduates (CMGs) to work in Canada and Newfoundland and Labrador (NL). In 2004, 66.8% of the residents were in Canada (87.8% MUN graduates, 47.3% IMGs, 67.3% CMGs) and 18.8% were in NL (43.2% MUN graduates, 7.9% IMGs, 4.8% CMGs). Compared to MUN medical graduates, IMGs and CMGs were less likely to work in Canada and NL.
PMCID: PMC2645180  PMID: 19305779
OBJECTIVES
1) To describe how internal medicine residency programs fulfill the Accreditation Council for Graduate Medical Education (ACGME) scholarly activity training requirement including the current context of resident scholarly work, and 2) to compare findings between university and nonuniversity programs.
DESIGN
Cross-sectional mailed survey.
SETTING
ACGME-accredited internal medicine residency programs.
PARTICIPANTS
Internal medicine residency program directors.
MEASUREMENTS
Data were collected on 1) interpretation of the scholarly activity requirement, 2) support for resident scholarship, 3) scholarly activities of residents, 4) attitudes toward resident research, and 5) program characteristics. University and nonuniversity programs were compared.
MAIN RESULTS
The response rate was 78%. Most residents completed a topic review with presentation (median, 100%) to fulfill the requirement. Residents at nonuniversity programs were more likely to complete case reports (median, 40% vs 25%; P =.04) and present at local or regional meetings (median, 25% vs 20%; P =.01), and were just as likely to conduct hypothesis-driven research (median, 20% vs 20%; P =.75) and present nationally (median, 10% vs 5%; P =.10) as residents at university programs. Nonuniversity programs were more likely to report lack of faculty mentors (61% vs 31%; P <.001) and resident interest (55% vs 40%; P =.01) as major barriers to resident scholarship. Programs support resident scholarship through research curricula (47%), funding (46%), and protected time (32%).
CONCLUSIONS
Internal medicine residents complete a variety of projects to fulfill the scholarly activity requirement. Nonuniversity programs are doing as much as university programs in meeting the requirement and supporting resident scholarship despite reporting significant barriers.
doi:10.1111/j.1525-1497.2005.40270.x
PMCID: PMC1490049  PMID: 15836549
ACGME; resident research; medical education; national survey
Canadian Family Physician  2005;51(9):1243.
OBJECTIVE
To compare the demographic and educational characteristics of Canadian international medical graduates (IMGs) and immigrant IMGs who applied to the second iteration of the Canadian Resident Matching Service (CaRMS) match in 2002.
DESIGN
Web-based questionnaire survey.
SETTING
The study was conducted during the second-iteration CaRMS match in Canada.
PARTICIPANTS
The sampling frame included the entire population of IMG registrants for the 2002 CaRMS match in Canada who expressed interest in applying for a ministry-funded residency position in the 13 English-speaking Canadian medical schools. Those who immigrated to Canada with medical degrees were categorized as immigrant IMGs. Canadian citizens and landed immigrants or permanent residents who left Canada to obtain a medical degree in another country were defined as Canadian IMGs.
MAIN OUTCOME MEASURES
Demographic characteristics, education and training outside Canada, examinations taken, previous applications for a residency position, preferred type of practice, and barriers and supports were compared.
RESULTS
Out of 446 respondents who indicated their immigration status and education, 396 (88.8%) were immigrant IMGs and 50 (11.2%) were Canadian IMGs. Immigrant IMGs tended to be older, be married, and have dependent children. Immigrant IMGs most frequently obtained their medical education in Asia, Eastern Europe, the Middle East, or Africa, whereas Canadian IMGs most frequently obtained their medical degrees in Asia, the Caribbean, or Europe. Immigrant IMGs tended to have more years of postgraduate training and clinical experience. A significantly greater proportion of immigrant IMGs had perceived that there were insufficient opportunities for assessment, financial barriers to training, and licensing barriers to practice. Nearly half (45.5%) of all IMGs selected family medicine as their first choice of clinical discipline to practise in Canada. There were no significant differences between Canadian and immigrant IMGs in terms of first choice of clinical discipline (family medicine vs specialty). There were no significant differences between the groups in the number of times they applied to CaRMS in the past, but a relatively greater proportion of Canadian IMGs obtained residency positions.
CONCLUSION
There are notable similarities and some significant differences between Canadian and immigrant IMGs seeking to practise medicine in Canada.
PMCID: PMC1479472  PMID: 16926941
Introduction
The Department of Graduate Medical Education at Stanford Hospital and Clinics has developed a professional training program for program directors. This paper outlines the goals, structure, and expected outcomes for the one-year Fellowship in Graduate Medical Education Administration program.
Background
The skills necessary for leading a successful Accreditation Council for Graduate Medical Education (ACGME) training program require an increased level of curricular and administrative expertise. To meet the ACGME Outcome Project goals, program directors must demonstrate not only sophisticated understanding of curricular design but also competency-based performance assessment, resource management, and employment law. Few faculty-development efforts adequately address the complexities of educational administration. As part of an institutional-needs assessment, 41% of Stanford program directors indicated that they wanted more training from the Department of Graduate Medical Education.
Intervention
To address this need, the Fellowship in Graduate Medical Education Administration program will provide a curriculum that includes (1) readings and discussions in 9 topic areas, (2) regular mentoring by the director of Graduate Medical Education (GME), (3) completion of a service project that helps improve GME across the institution, and (4) completion of an individual scholarly project that focuses on education.
Results
The first fellow was accepted during the 2008–2009 academic year. Outcomes for the project include presentation of a project at a national meeting, internal workshops geared towards disseminating learning to peer program directors, and the completion of a GME service project. The paper also discusses lessons learned for improving the program.
doi:10.4300/01.01.0024
PMCID: PMC2931184  PMID: 21975722
Medical Education Online  2013;18:10.3402/meo.v18i0.21612.
Background
The Accreditation Council for Graduate Medical Education (ACGME) requires that training programs integrate system-based practice (SBP) and practice-based learning and improvement (PBLI) into internal medicine residency curricula.
Context and setting
We instituted a seminar series and year-long-mentored curriculum designed to engage internal medicine residents in these competencies.
Methods
Residents participate in a seminar series that includes assigned reading and structured discussion with faculty who assist in the development of quality improvement or research projects. Residents pursue projects over the remainder of the year. Monthly works in progress meetings, protected time for inquiry, and continued faculty mentorship guide the residents in their project development. Trainees present their work at hospital-wide grand rounds at the end of the academic year. We performed a survey of residents to assess their self-reported knowledge, attitudes and skills in SBP and PBLI. In addition, blinded faculty scored projects for appropriateness, impact, and feasibility.
Outcomes
We measured resident self-reported knowledge, attitudes, and skills at the end of the academic year. We found evidence that participants improved their understanding of the context in which they were practicing, and that their ability to engage in quality improvement projects increased. Blinded faculty reviewers favorably ranked the projects’ feasibility, impact, and appropriateness. The ‘Curriculum of Inquiry’ generated 11 quality improvement and research projects during the study period. Barriers to the ongoing work include a limited supply of mentors and delays due to Institutional Review Board approval. Hospital leadership recognizes the importance of the curriculum, and our accreditation manager now cites our ongoing work.
Conclusions
A structured residency-based curriculum facilitates resident demonstration of SBP and practice-based learning and improvement. Residents gain knowledge and skills though this enterprise and hospitals gain access to trainees who help to solve ongoing problems and meet accreditation requirements.
doi:10.3402/meo.v18i0.21612
PMCID: PMC3776321  PMID: 24044686
graduate medical education; competencies; longitudinal curriculum

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