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1.  The United States Physician Workforce and International Medical Graduates: Trends and Characteristics 
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
2.  The United States Physician Workforce and International Medical Graduates: Trends and Characteristics 
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
3.  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.
doi:10.1007/BF02351505
PMCID: PMC3456700  PMID: 10609597
Cities; Foreign Medical Graduates; International Medical Graduates; Physician Distribution; Physician Supply; Poverty; Urban Areas
4.  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
5.  Career Satisfaction in Primary Care: A Comparison of International and US Medical Graduates 
ABSTRACT
BACKGROUND
International medical graduates (IMGs) have substantial representation among primary care physicians in the USA and consistently report lower career satisfaction compared with US medical graduates (USMGs). Low career satisfaction has adverse consequences on physician recruitment and retention.
OBJECTIVE
This study aims to identify factors that may account for or explain lower rates of career satisfaction in IMGs compared with USMGs.
DESIGN
Using data from the 2008 Health Tracking Physician Survey, a nationally representative survey, we examined the association between IMG status and career satisfaction among primary care physicians. We used multivariable logistic regression modeling to adjust for a broad range of potential explanatory factors and physician characteristics.
PARTICIPANTS
The study participants comprise primary care physicians who reported at least 20 h a week of direct patient care activities (N = 1,890).
MAIN MEASURES
The main measures include respondents’ overall satisfaction with their careers in medicine.
KEY RESULTS
IMGs were statistically significantly less likely than USMGs to report career satisfaction (75.7% vs. 82.3%; p = 0.005). This difference persisted after adjusting for physician characteristics and variables describing the practice environment (adjusted odds ratio = 0.62; 95% confidence interval, 0.43–0.90). Pediatricians (vs. internists) and those who earned $200,001–250,000 (vs. <$100,000) or >$250,000 were more likely to report career satisfaction, while solo practitioners and those who reported being unable to provide high-quality patient care were less likely to report career satisfaction.
CONCLUSIONS
After adjusting for a number of variables previously shown to have an impact on career satisfaction, we were unable to identify additional factors that could account for or explain differences in career satisfaction between IMGs and USMGs. In light of the central role of IMGs in primary care, the potential impact of poorer satisfaction among IMGs may be substantial. Improved understanding of the causes of this differential satisfaction is important to appropriately support the primary care physician workforce.
doi:10.1007/s11606-011-1832-4
PMCID: PMC3270248  PMID: 21866306
workforce; primary care; physician satisfaction
6.  Initial Practice Locations of International Medical Graduates 
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
7.  The US Distribution of Physicians from Lower Income Countries 
PLoS ONE  2012;7(3):e33076.
Introduction
Since the 1960 s, the number of international medical graduates (IMGs) in the United States has increased significantly. Given concerns regarding the effects of this loss to their countries of origin, the authors undertook a study of IMGs from lower income countries currently practicing in the United States.
Methods
The AMA Physician Masterfile was accessed to identify all 265,851 IMGs in active practice in the United States. These were divided by state of practice and country of origin. World Bank income classification was used to identify lower income countries.
Results
128,729 IMGs were identified from 53 lower income countries, constituting 15 percent of the US active physician workforce. As a percentage of the workforce, West Virginia (29%), New Jersey (27%), and Michigan (26%) had the most IMGs from lower income countries, and Montana, Idaho, and Alaska (all less than 2%), the least. The countries with the greatest loss of physicians to the United States per 100,000 population were the Philippines, Syria, Jordan, and Haiti.
Discussion
The reliance of US medicine on physicians from lower income countries is beneficial to the United States both clinically and economically. However, it results in a loss of the lower income country's investment in the IMG's education. We discuss possible mechanisms to compensate the lower income countries for the medical education costs of their physicians who immigrate to the US.
doi:10.1371/journal.pone.0033076
PMCID: PMC3310056  PMID: 22457735
8.  Did the post war repatriation of Lebanese physicians drive recent Lebanese medical graduates to emigrate? An observational study 
Background
A significant number of Lebanese medical graduates have emigrated from Lebanon. The objective of this study was to evaluate the hypothesis that the repatriation of Lebanese physicians educated abroad has contributed to the international emigration of recent Lebanese medical graduates.
Methods
We analyzed the demographic and educational characteristics and the year of registration of physicians registered with the two physician associations in Lebanon as of 2007. We then analyzed the number of new and total registrants and the physician density for the years 1977–2006. Finally we calculated the percentage of Lebanese graduates of the years 1977–2006 registered as of 2007.
Results
As of 2007, 10,918 physicians were registered in Lebanon. Most were male (80.4%) and graduated from either Lebanese (36.4%) or Eastern European (30.6%) medical schools. The top three regions of specialty training were Western Europe (31.8%), Eastern Europe (28.4%) and Lebanon (25.7%). About half the physicians registered with the Lebanese Order of Physicians as of 2007 joined during the 1990s decade; only 26.2% of these graduated from Lebanese medical schools during that decade. The number of new registrants increased dramatically in the early 1990s and started decreasing in the early 2000s. About 60% of Lebanese medical graduates of the years 1977–2006 were registered in Lebanon as of 2007. Categorizing Lebanese medical graduates by their year of graduation, the percentage registered in Lebanon as of 2007 showed a "dip" for those who graduated in the early 1990s.
Conclusion
The high number of physicians educated abroad returning to Lebanon after the end of the civil war may have driven recent Lebanese medical graduates to emigrate.
doi:10.1186/1472-6963-8-195
PMCID: PMC2559837  PMID: 18816380
9.  Comparing United States versus International Medical School Graduate Physicians Who Serve African- American and White Elderly 
Health Services Research  2006;41(6):2155-2181.
Objective
To examine the relationship that international medical school graduates (IMGs) in comparison with United States medical school graduates (USMGs) have on health care-seeking behavior and satisfaction with medical care among African-American and white elderly.
Data Sources
Secondary data analysis of the 1986–1998 Piedmont Health Survey of the Elderly, Established Populations for the Epidemiological Study of the Elderly, a racially oversampled urban and rural cohort of elders in five North Carolina counties.
Study Design
Primary focus of analyses examined the impact of the combination of elder race and physician graduate status across time using a linear model for repeated measures analyses and χ2 tests. Separate analyses using generalized estimating equations were conducted for each measure of elder characteristic and health behavior. The analytic cohort included 341 physicians and 3,250 elders (65 years old and older) in 1986; by 1998, 211 physicians and 1,222 elders.
Data Collection/Extraction Methods
Trained personnel collected baseline measures on 4,162 elders (about 80 percent responses) through 90-minute in-home interviews.
Principal Findings
Over time, IMGs treated more African-American elders, and those who had less education, lower incomes, less insurance, were in poorer health, and who lived in rural areas. White elders with IMGs delayed care more than those with USMGs. Both races indicated being unsure about where to go for medical care. White elders with IMGs were less satisfied than those with USMGs. Both races had perceptions of IMGs that relate to issues of communication, cultural competency, ageism, and unnecessary expenses.
Conclusion
IMGs do provide necessary and needed access to medical care for underserved African Americans and rural populations. However, it is unclear whether concerns regarding cultural competency, communication and the quality of care undermine the contribution IMGs make to these populations.
doi:10.1111/j.1475-6773.2006.00587.x
PMCID: PMC1955313  PMID: 17116114
African-American elderly; international medical school graduate physicians; United States medical school graduate physicians; satisfaction with medical care; health care-seeking behavior
10.  International medical graduates in the USA: a qualitative study on perceptions of physician migration 
BMJ Open  2011;1(2):e000138.
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.
Article summary
Article focus
International medical graduates (IMGs) play a significant role in the health workforce in many nations.
Prior literature has largely limited the consideration of physician migration to isolated factors such as financial pressures in the home country or expanded training opportunities in the USA.
The experiences and perspectives of IMGs have not been included in current discussions surrounding physician migration.
Key messages
Physician migration is influenced by multi-faceted aspects of experience including individual, environmental and political factors.
IMGs report that both local and global health workforce policies have an impact on their personal and professional lives.
A comprehensive understanding of physician migration is essential to the development of effective and appropriate solutions for global health workforce challenges.
Strengths and limitations of this study
Participants were diverse with regard to age, specialty, geographical regions of origin and years of clinical experience in the USA.
The study utilised recommended strategies to ensure rigour.
The high participation rate suggests this is an issue IMGs are motivated to discuss despite the potentially personal and sensitive nature of the topic.
As a qualitative study, the hypotheses generated should be tested with larger, quantitative studies.
The study was geographically circumscribed to metropolitan regions. Other regions, particularly rural areas, may present a substantially different environment and experience.
doi:10.1136/bmjopen-2011-000138
PMCID: PMC3191587  PMID: 22021871
11.  Career intentions of U.S. medical graduates and international medical graduates. 
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
12.  Retention of International Medical Graduates Following Postgraduate Medical Training in Newfoundland and Labrador 
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
13.  Retention of provisionally licensed international medical graduates: a historical cohort study of general and family physicians in Newfoundland and Labrador  
Open Medicine  2008;2(2):e62-e69.
Background
To alleviate the shortage of primary care physicians in rural communities, the Canadian province of Newfoundland and Labrador (NL) introduced provisional licensure for international medical graduates (IMGs), allowing them to practise in under-served communities while completing licensing requirements. Although provisional licensing has been seen as a needed recruitment strategy, little is known about its impact on physician retention. To assess the relationship between provincial retention time and type of initial practice licence, we compared the retention of: (1) IMGs who began practice with a provisional licence; (2) fully licensed Memorial University medical graduates (MMGs); and (3) fully licensed medical graduates from other Canadian medical schools (CMGs).
Methods
Using administrative data from the NL College of Physicians and Surgeons, the 2004 Scott’s Medical Database, and the Memorial University postgraduate database, we identified family physicians/general practitioners (FPs/GPs) who began their practice in NL in the period 1997–2000 and determined where they were in 2004. We used Cox regression to examine differences in retention among these 3 groups of physicians.
Results
There were 42 MMGs, 38 CMGs and 77 IMGs in our sample. The median time for IMGs to qualify for full licensure was 15 months. Twenty-one physicians (13.4%) stayed in NL after beginning their practice (35.7% MMGs, 5.3% CMGs, 5.2% IMGs; p < 0.000). The median retention time was 25 months (MMGs, 39 months; CMGs, 22 months; IMGs, 22 months; p < 0.000). After controlling for Certificant of the College of Family Physicians status, CMGs (hazard ratio [HR] = 2.15; 95% confidence interval [CI] 1.29–3.60) and IMGs (HR = 2.03; 95% CI 1.26–3.27) were more likely to leave NL than MMGs.
Conclusions
Provisional licensing accounts for the largest proportion of new primary care physicians in NL but does not lead to long-term retention of IMGs. However, IMG retention is no worse than the retention of CMGs.
PMCID: PMC3090179  PMID: 21602945
14.  The dilemma of physician shortage and international recruitment in Canada 
The perception of physician shortage in Canada is widespread. Absolute shortages and relative discrepancies, both specialty-wise and in urban-rural distribution, have been a daunting policy challenge. International Medical Graduates (IMGs) have been at the core of mitigating this problem, especially as long as shortage of physicians in rural areas is concerned. Considering such recruitment as historical reality is naïve annotation, but when it is recommended per se, then the indication of interest overweighs the intent of ethically justified solution. Such a recommendation has not only invited policy debate and disagreement, but has also raised serious ethical concerns. Canadian healthcare policy-makers were put into a series of twisting puzzles—recruiting IMGs in mitigating physician shortage was questioned by lack of vision for Canada’s self-sufficiency. In-migration of IMGs was largely attributed to Canada’s point-based physician-friendly immigration system without much emphasizing on IMGs’ home countries’ unfavorable factors and ignoring their basic human rights and choice of livelihood. While policy-makers’ excellence in integrating the already-migrated IMGs into the Canadian healthcare is cautiously appraised, its logical consequence in passively drawing more IMGs is loudly criticised. Even the passive recruitment of IMGs raised the ethical concern of source countries’ (which are often developing countries with already-compromised healthcare system) vulnerability. The current paper offers critical insights juxtaposing all these seemingly conflicting ideas and interests within the scope of national and transnational instruments.
doi:10.15171/ijhpm.2014.53
PMCID: PMC4075100  PMID: 24987719
Physician Shortage;  Canada, International Recruitment, Ethical Conce;  Ethical Concern;  International Medical Graduates (IMGs)
15.  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
16.  Retention of specialist physicians in Newfoundland and Labrador 
Open Medicine  2012;6(1):e1-e9.
Background
Although specialist physicians comprise nearly half of the physician workforce in Newfoundland and Labrador (NL), relatively little is known about their retention patterns. We compared 2 cohorts of physicians who were initially licensed to practise in NL between 1993 and 1997 and between 2000 and 2004, to examine whether retention had changed over time. Additionally, we examined the retention of 4 groups of physicians in each cohort: (1) fully licensed medical graduates of Memorial University, (2) fully licensed medical graduates of other Canadian universities, (3) provisionally licensed international medical graduates (IMGs) and (4) fully licensed IMGs. Provisional licences allow physicians who have not received Canadian certification to practise while obtaining credentials. We hypothesized that fully licensed physicians (largely physicians who are locally trained) would remain in NL longer than provisionally licensed physicians (largely IMGs).
Methods
Using data from the provincial medical registrar and Memorial University’s office of postgraduate medical education, we used survival analysis (Cox regression) to compare the retention of the 2 cohorts and the 4 groups of physicians within each cohort.
Results
After 48 months, roughly 60% of the physicians in the 2000–04 cohort and 45% of the physicians in the 1993–97 cohort remained in NL. Medical graduates of Memorial Universitycomprised 61/180 (33.9%) of the 2000–04 cohort and 38/211 (18.0%) of the 1993–97 cohort.Physicians in the 2000–04 cohort were 1.6 (95% confidence interval [CI] 1.23–2.08) times less likely to leave NL than physicians in the 1993–97 cohort. In the 2000–04 cohort, medical graduates of Canadian universities, provisionally licensed IMGs and fully licensed IMGs were 3.19 (95% CI 1.47–6.89), 1.85 (95% CI 1.09–3.17) and 4.39 (95% CI 1.91–10.10) times more likely to leave NL than medical graduates of Memorial University. In the 1993–97 cohort, IMGs with provisional licences were 2.16 (95% CI 1.37–3.42) times more likely to leave NL than medical graduates of Memorial University. There was no significant difference in retention between medical graduates of Memorial University and other Canadian universities or IMGs with full licences in the 1993–97 cohort.
Interpretation
The improvement in the retention of specialist physicians in NL since the 1990s may be attributable to the increase in the relative proportion of medical graduates of Memorial University. Although provisional licensing enables IMGs to begin practice in NL, it does not lead to long-term retention.
PMCID: PMC3329069  PMID: 22567077
17.  Canadian and immigrant international medical graduates 
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
18.  Predicting performance using background characteristics of international medical graduates in an inner-city university-affiliated Internal Medicine residency training program 
Background
IMGs constitute about a third of the United States (US) internal medicine graduates. US residency training programs face challenges in selection of IMGs with varied background features. However data on this topic is limited. We analyzed whether any pre-selection characteristics of IMG residents in our internal medicine program are associated with selected outcomes, namely competency based evaluation, examination performance and success in acquiring fellowship positions after graduation.
Methods
We conducted a retrospective study of 51 IMGs at our ACGME accredited teaching institution between 2004 and 2007. Background resident features namely age, gender, self-reported ethnicity, time between medical school graduation to residency (pre-hire time), USMLE step I & II clinical skills scores, pre-GME clinical experience, US externship and interest in pursuing fellowship after graduation expressed in their personal statements were noted. Data on competency-based evaluations, in-service exam scores, research presentation and publications, fellowship pursuance were collected. There were no fellowships offered in our hospital in this study period. Background features were compared between resident groups according to following outcomes: (a) annual aggregate graduate PGY-level specific competency-based evaluation (CBE) score above versus below the median score within our program (scoring scale of 1 – 10), (b) US graduate PGY-level specific resident in-training exam (ITE) score higher versus lower than the median score, and (c) those who succeeded to secure a fellowship within the study period. Using appropriate statistical tests & adjusted regression analysis, odds ratio with 95% confidence intervals were calculated.
Results
94% of the study sample were IMGs; median age was 35 years (Inter-Quartile range 25th – 75th percentile (IQR): 33–37 years); 43% women and 59% were Asian physicians. The median pre-hire time was 5 years (IQR: 4–7 years) and USMLE step I & step II clinical skills scores were 85 (IQR: 80–88) & 82 (IQR: 79–87) respectively. The median aggregate CBE scores during training were: PG1 5.8 (IQR: 5.6–6.3); PG2 6.3 (IQR 6–6.8) & PG3 6.7 (IQR: 6.7 – 7.1). 25% of our residents scored consistently above US national median ITE scores in all 3 years of training and 16% pursued a fellowship.
Younger residents had higher aggregate annual CBE score than the program median (p < 0.05). Higher USMLE scores were associated with higher than US median ITE scores, reflecting exam-taking skills. Success in acquiring a fellowship was associated with consistent fellowship interest (p < 0.05) and research publications or presentations (p <0.05). None of the other characteristics including visa status were associated with the outcomes.
Conclusion
Background IMG features namely, age and USMLE scores predict performance evaluation and in-training examination scores during residency training. In addition enhanced research activities during residency training could facilitate fellowship goals among interested IMGs.
doi:10.1186/1472-6920-9-42
PMCID: PMC2717068  PMID: 19594918
19.  Self-reported Fluency in Non-English Languages Among Physicians Practicing in California 
Family medicine  2010;42(6):414-420.
Background and Objectives
With increasing numbers of people with limited English proficiency in the United States, there is growing concern about the potential adverse effect of language barriers on patient care. We sought to compare the non-English language fluency of practicing physicians by physician race/ethnicity and location of medical school education.
Methods
We used cross-sectional analyses of California Medical Board Survey (2007) data of 61,138 practicing physicians. Measures examined were self-reported physician language fluency in 34 languages, race/ethnicity, and medical school of graduation.
Results
Forty-two percent of physicians reported having fluency in at least one language other than English. Fifty-six percent of international medical graduates (IMGs) reported fluency in a language other than English, compared to 37% of US medical graduates (USMG). Although the majority of physicians with fluency in Spanish are not Latino, fluency in Asian languages is primarily restricted to physicians who are of Asian race/ethnicity. Eighty-seven percent of physicians with fluency in Mandarin, Cantonese, or other Chinese languages are of Chinese ethnicity. A similar association between ethnicity and fluency was found for Southeast Asian languages, Pacific Island languages, and South Asian languages. IMGs constituted more than 80% of the physicians with fluency in Arabic, South Asian, and Pacific Islander languages.
Conclusions
IMGs contribute to the diversity of languages spoken by California physicians.
PMCID: PMC4073200  PMID: 20526909
20.  Professional Experiences of International Medical Graduates Practicing Primary Care in the United States 
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
21.  “Brain drain” and “brain waste”: experiences of international medical graduates in Ontario 
Background
“Brain drain” is a colloquial term used to describe the migration of health care workers from low-income and middle-income countries to higher-income countries. The consequences of this migration can be significant for donor countries where physician densities are already low. In addition, a significant number of migrating physicians fall victim to “brain waste” upon arrival in higher-income countries, with their skills either underutilized or not utilized at all. In order to better understand the phenomena of brain drain and brain waste, we conducted an anonymous online survey of international medical graduates (IMGs) from low-income and middle-income countries who were actively pursuing a medical residency position in Ontario, Canada.
Methods
Approximately 6,000 physicians were contacted by email and asked to fill out an online survey consisting of closed-ended and open-ended questions. The data collected were analyzed using both descriptive statistics and a thematic analysis approach.
Results
A total of 483 IMGs responded to our survey and 462 were eligible for participation. Many were older physicians who had spent a considerable amount of time and money trying to obtain a medical residency position. The top five reasons for respondents choosing to emigrate from their home country were: socioeconomic or political situations in their home countries; better education for children; concerns about where to raise children; quality of facilities and equipment; and opportunities for professional advancement. These same reasons were the top five reasons given for choosing to immigrate to Canada. Themes that emerged from the qualitative responses pertaining to brain waste included feelings of anger, shame, desperation, and regret.
Conclusion
Respondents overwhelmingly held the view that there are not enough residency positions available in Ontario and that this information is not clearly communicated to incoming IMGs. Brain waste appears common among IMGs who immigrate to Canada and should be made a priority for Canadian policy-makers.
doi:10.2147/RMHP.S60708
PMCID: PMC4027850  PMID: 24868176
global health; human resources
22.  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
23.  The Canadian contribution to the US physician workforce 
Background
A physician shortage has been declared in both Canada and the United States. We sought to examine the migration pattern of Canadian-trained physicians to the United States, the contribution of this migration to the Canadian physician shortage and policy options in light of competing shortages in both countries.
Methods
We performed a cross-sectional analysis of the 2004 and 2006 American Medical Association Physician Masterfiles, the 2002 Area Resource File and data from the Canadian Institute for Health Information, the Canadian Medical Association and the Association of Faculties of Medicine of Canada. We describe the migration pattern of Canadian medical school graduates to the United States, the number of Canadian-trained physicians in the United States in 2006, the proportion who were in active practice, the proportion who were practising in rural or underserved areas and the annual contribution of Canadian-trained physicians to the US physician workforce.
Results
Two-thirds of the 12 040 Canadian-educated physicians living in the United States in 2006 were practising in direct patient care, 1023 in rural areas. About 186, or 1 in 9, Canadian-educated physicians from each graduating class joined the US physician workforce providing direct patient care. Canadian-educated physicians are more likely than US-educated physicians to practise in rural areas.
Interpretation
Minimizing emigration, and perhaps recruiting physicians to return to Canada, could reduce physician shortages, particularly in subspecialties and rural areas. In light of competing physician shortages, it will be important to consider policy options that reduce emigration, improve access to care and reduce reliance on physicians from developing countries.
doi:10.1503/cmaj.060525
PMCID: PMC1839794  PMID: 17420490
24.  Comparison of International Medical Graduates with US Medical Students and Residents after a Four-Week Course in Palliative Medicine: A Pilot Study 
Journal of Palliative Medicine  2013;16(5):471-477.
Abstract
Background
The need for doctors who have skills in pain management and palliative medicine is greatest in low and moderate resource countries where patients most frequently present to their health care system with advanced illness and greater than 80% of the global deaths occur. While medical students trained in the United States are required to have training in palliative medicine, international medical graduates (IMGs), who have completed medical school outside North America, may not have the same exposure to palliative medicine training as U.S. physicians. The goal of this study was to evaluate whether a four-week course in palliative medicine could bring IMG attitudes, concerns, competence, and knowledge to the level of U.S. trainees.
Methods
As part of a prospective cohort study, 21 IMGs from 14 countries participated in a four-week course in palliative medicine. Attitudes, concerns, self-reported competence, and knowledge were assessed pre-course and post-course. The course was evaluated weekly and at the end of the four-week program. The data from the IMGs was compared to data from U.S. medical students and residents using the same assessment tools.
Results
After the course, IMGs had significantly decreased concern about ethical and legal issues in palliative medicine to the level of U.S.-trained residents and a significant increase in knowledge and self-rated competence equivalent to the level of U.S. trainees.
Conclusions
A four-week course in palliative medicine can improve the levels of concern, knowledge and self-assessed competence in IMGs to the level of US trainees.
doi:10.1089/jpm.2012.0478
PMCID: PMC3713437  PMID: 23448688
25.  Analysis of International Migration Patterns Affecting Physician Supply in Canada 
Healthcare Policy  2008;3(4):e129-e138.
This paper analyzes the migration patterns of both Canadian medical school graduates and international medical graduates (IMGs), and the impact of these patterns on physician supply in Canada. Immigration patterns of IMGs have changed over time, with fewer physicians from the United Kingdom and more from South Africa. A large portion of IMGs who leave Canada (43%) return “home.” Recently, the average duration of practice in Canada for these doctors has been three years, a finding that suggests many came for educational purposes or to acquire skills. The heterogeneity and complexity of international migration are highlighted in this paper.
PMCID: PMC2645159  PMID: 19377319

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