Coming to America — International Medical Graduates in the United States
Graham T. McMahon, M.B., B.Ch.
They can't believe that I round at 6:30 a.m., that I am available to my
patients 24 hours a day, or that I don't get paid overtime for long hours.
My medical school classmates who continue to work in Ireland live a
different life from mine — one that I have left behind.
But I am not alone. International medical graduates account for a quarter of
the 853,187 physicians in the United States,1 an increase of 160 percent
since 1975. Immigrant physicians also account for 27 percent of the country'
s 96,937 residents and fellows,1 having migrated in search of training and
career opportunities that are unavailable in their home countries.
An examination of the U.S. physician workforce suggests that there is an
ever-increasing dependence on international medical graduates. Although the
number of physicians in the United States has increased at twice the rate of
population growth in the past 10 years, many urban and rural communities
continue to have shortages of physicians. Recently, the federal Council on
Graduate Medical Education, in response to the findings of a study that it
commissioned, acknowledged that the country appeared to be on the verge of a
serious shortage of physicians and endorsed a recommendation that medical
schools and training programs increase their enrollments over the next
decade to help offset a future shortfall of doctors.2 Primary care practices
are likely to be the hardest hit; perceived challenges to a high quality of
life and decreasing reimbursement rates for office visits have eroded the
attractiveness of primary care specialties to graduates of U.S. medical
schools. International medical graduates have consistently provided a safety
net for such programs, hospitals, and areas of shortage. Some 40 percent of
primary care programs in the United States are already dependent on
immigrant physicians,3 and a full two thirds of international graduates
serve in hospitals that provide a disproportionate share of care for the
poor in this country.3
The transition to life in the United States can be fraught with unexpected
challenges for doctors who have trained abroad. Professional and doctor–
patient relationships can be distinctly different from what they are used to
. Physicians who have practiced abroad report that U.S. patients have higher
expectations of their doctors' availability and the services to be provided
. Patients here almost universally receive their hospital care in the
privacy of a one-bed or two-bed room, whereas hospitals in Europe and Asia
feature communal wards with their resultant microcommunities of nurses,
aides, and doctors. Immigrant physicians can be disoriented by their
different role within the health care team. Schooling in the United States
strongly emphasizes evidence-based practice and the use of technology over
personal style and traditional approaches, and nonphysician health care
professionals have more responsibility in the U.S. system than elsewhere.
Add in the need to learn hundreds of new brand names and laboratory values
and to adjust to differently formatted medical notes, and it is hardly
surprising that these adaptive challenges can be overwhelming for the newly
Both physicians and their patients can find language barriers frustrating.
Despite the requirement of the Educational Commission for Foreign Medical
Graduates (ECFMG) for the demonstration of competence in English, only
physicians with previous immersion among English speakers can reach the
level of fluency that is typically required for discussions about medical
decisions. When patients report what may be genuine problems with doctor–
patient communication, their complaints can be interpreted, rightly or
wrongly, as evidence of intolerance or racism and can strike a further blow
to the self-esteem of immigrants who are already struggling against
International physicians contribute much more than medical manpower and have
consistently infused every part of the United States with new ideas and
skills that have been critical to the nation's economic, scientific, and
cultural growth (see Figure). In addition to being overrepresented in the
groups that care for the country's most isolated and vulnerable citizens,
international medical graduates contribute enormously to the country's
research endeavors.4 Many of the world's most talented graduates seek U.S.
medical positions out of a desire to engage in constructive medical research
, for which few opportunities exist in their home nations. Despite this
ambition, it is more difficult for them than for U.S.-born graduates to eke
out a research career, since noncitizens are ineligible for training grants
from the National Institutes of Health (NIH) — a particular challenge,
since a large proportion of research fellowships are funded by such grants.
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Figure. Prevalence of International Medical Graduates throughout the
Data are from the American Medical Association, Physician Masterfile, 2004.
For many international medical graduates, gaining access to training in the
United States is an enormous challenge. No applicant is spared the stress of
the examinations, interviews, and licensing procedures or the tumult of
adaptation to a new culture, often undertaken without family and friends.
There is no reciprocal recognition of training between the United States and
the rest of the world, which means that practitioners who wish to immigrate
must complete an internship and a residency in the United States in order
to be eligible for board certification for independent practice here.
International graduates must demonstrate their readiness to enter U.S.
training by passing the steps of the United States Medical Licensing
Examination (USMLE) and the clinical-skills examination to fulfill the
requirements of the ECFMG. This series of examinations now costs nearly $3,
000, plus the cost of travel to the United States — a net amount
approximately equal to one year's salary for a physician from a low-income
nation. It is clear that these costs restrict access to the system for
candidates from impoverished nations; the introduction of the expensive
clinical-skills examination in 1998 halved the number of ECFMG certificates
issued in 1999.4 However, the examinations have made it easier for program
directors to compare the knowledge attainment of U.S. and international
graduates and have alleviated their qualms about judging the skills of
applicants who come from disparate regions (see Table).
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Table. The 10 Most Prevalent Non-U.S. Nationalities among International
Medical Graduates (IMGs) Working in the United States.
Multiple attempts to manage the medical workforce through the regulation of
the immigration of physicians and concern about siphoning off medical talent
from developing nations have resulted in a convoluted visa system involving
restrictions that are peculiar to the medical profession. Visas for
training purposes (J visas) may be sponsored by the ECFMG but require a
return to one's home nation for a minimum of two years after training is
completed; H1b "professional worker" visas provide broader opportunities but
require the applicant to have passed step 3 of the USMLE, to have secured
an offer of a training position, and to have been granted a temporary state
Since the United States depends on international medical graduates, much can
be done to facilitate the integration of the immigrant workforce into the U
.S. medical system. Peers and superiors of trainees can ease the process by
communicating their understanding of the unique challenges that newly
immigrated physicians face and allowing time for adaptation. Program
directors can support professional-worker visas for physicians in order to
facilitate their pursuit of diverse career paths, and expedited visa-
processing procedures can be implemented. English-immersion courses can be
extremely useful for some immigrants. And a reevaluation of the eligibility
rules for noncitizens that would enable them to receive research training
awards from the NIH and other sources may maximize the contribution of
international graduates — and perhaps invigorate the national research
enterprise in the process.
International medical graduates make an important contribution to the health
and well-being of the American people. Initiatives that encourage greater
participation of immigrant physicians in our clinical and research workforce
may allow us to build a health care system that is equitable not only for
these contributing physicians, but for the U.S. public itself.
From the Division of Endocrinology, Diabetes, and Hypertension, Brigham and
Women's Hospital, Boston.
Physician characteristics and distribution in the US, 2004-2005. Chicago:
AMA Press, 2003.
Council on Graduate Medical Education. Minutes of meeting, September 17,
2003. (Accessed May 20, 2004, at http://www.cogme.gov/minutes09_03.htm.)
Whitcomb ME, Miller RS. Participation of international medical graduates in
graduate medical education and hospital care for the poor. JAMA 1995;274:696
Whelan GP, Gary NE, Kostis J, Boulet JR, Hallock JA. The changing pool of
international medical graduates seeking certification training in US
graduate medical education programs. JAMA 2002;288:1079-1084.