How the United States depends on doctors trained in other countries

An excerpt from Doctors’ Orders: The Making of Status Hierarchies in an Elite Profession. Copyright (c) 2020 Tania M. Jenkins. Used by arrangement with the publisher. All rights reserved.

I met Trevor on his very first day of residency, at the start of three years of practical, on-the-ground training in internal medicine following medical school. He was of medium height with a closely shaven head and a strong build. Trevor was especially fond of white button-down shirts with sleeves rolled up to his elbows, revealing olive-toned forearms. He wore his stethoscope slung over one shoulder—like a purse—and even as a first-year resident (intern), he possessed a quiet calm that was appealing in a doctor.

Trevor had known he wanted to go into medicine from a young age. After going to private elementary and high school in Michigan and graduating from the University of Michigan, he applied to only three medical schools—all in Southeast Asia. It made sense to him financially: “I thought about going to the Caribbean but cost-wise, you know, I was going to be paying U.S. prices. My four years in [Southeast Asia], including housing, tuition, a car, all the miscellaneous costs, it probably cost me in the ballpark of maybe 80K for four years.” Tuition and living expenses for medical school in the United States or the Caribbean averaged about three to four times that amount, so Trevor reasoned he had made a sound financial choice.

He was picky, however, about which medical schools he applied to in Southeast Asia. He applied only to programs that would allow him to do clinical rotations in the United States, knowing that he eventually wanted to come back to the United States for residency. “I wanted to have more exposure to the U.S. system, whether it be rotations or just [learning] how medicine is practiced [here],” he explained, adding, “I think a lot of [residency] programs—especially for us foreigners—they like it when we have U.S. clinical experience.” I remember being startled by his expression: “us foreigners.” Trevor was born and raised in Ann Arbor. When I pointed this out to him, he shrugged and said, “Actually, in terms of residency, everyone is kind of split up by either U.S. grad or foreign grad, so whether I was born here or not, they would still classify me as a foreign grad. . . . [We’re American] in every aspect except for how the medical field views us basically.”

Every year the United States relies on thousands of medical graduates like Trevor to fill postgraduate residency positions because it does not produce enough doctors to meet its own needs. In 2019, nearly 19,000 American allopathic medical school seniors (USMDs) vied for over 32,000 first-year residency positions. Nearly 94 percent of them were successful, but even if 100 percent had “matched” to a residency, there would still have been more than 13,000 positions left over. That means the United States does not graduate enough M.D.s by about a third every year. In fact, since the advent of modern residency training in the 1950s, the United States has produced 20 to 45 percent fewer M.D.s than are needed to staff residency positions nationwide.

To fill the gap, the United States depends on doctors trained in other countries and traditions. In 2019, nearly 10 percent of first-year residency positions were filled by U.S. citizens who were international medical graduates (USIMGs). These are Americans, like Trevor, who take a nontraditional route into medicine by studying overseas (most often in the Caribbean) and coming back to the United States to complete their required residency training. Most USIMGs complete roughly two years of classroom instruction abroad and then finish the last two years of their clinical education in the United States, preparing them for residency positions in the U.S. health care system. Around 55 percent of USIMG applicants successfully matched to residency positions in the United States in 2019.

Another 13 percent of first-year residency positions were filled by international medical graduates who are not U.S. citizens (IMGs). These individuals complete at least undergraduate medical training abroad before deciding to pursue graduate medical education in the United States. Some come to the United States as fully trained, experienced physicians, but all must still complete residency training in the United States before becoming eligible to practice independently. A little more than half (53.4 percent) of all IMG applicants were able to match to a residency program in 2019.

Residency, therefore, is hardly a given for non-USMDs while it is all but guaranteed for USMDs. For these reasons, I refer to all international and osteopathic medical graduates (USIMGs, IMGs, and DOs) jointly as non-USMDs in order to contrast them with USMDs. The non-USMDs in each category have distinct histories, trajectories, and perspectives, but what all three groups have in common is this: they are systematically relied upon to fill gaps in the U.S. health care system, yet the medical profession views and treats them differently than USMDs.

Despite representing a sizable chunk of new resident physicians each year, non-USMDs often do not end up in the same specialties as USMDs. Highly prestigious and sought-after fields, such as otolaryngology (also known as ear, nose, and throat) and orthopedic surgery are almost exclusively staffed by USMDs while less prestigious areas like pathology, family medicine, and internal medicine are dominated by non-USMDs.

Even within the specialties that they dominate, non-USMDs oft do not match to the same kinds of programs as USMDs, although mean licensing exam scores—one of the biggest predictors of residency placement—are virtually identical between matched USMDs and at least matched international graduates. In fact, on one particularly critical test—Step 1 of the United States Medical Licensing Exam (USMLE)— non-U.S. citizen international medical graduates (IMGs) actually outperform U.S.-citizen MDs (i.e., USMDs and USIMGs) and D.O.s.  Furthermore, for the same exact test scores, non-USMDs generally have a much lower probability of matching to their preferred specialty than USMDs do.

Still, USMDs tend to congregate in higher-status hospitals while non-USMDs fill positions in lower-status ones, often in less desirable geographic areas. In some cases, this has resulted in heavily segregated training environments. On the one hand, there are highly prestigious programs staffed mostly by USMDs in university hospitals, which tend to have lower patient-to-nurse ratios, higher procedure volumes, and state-of-the-art equipment and care processes. On the other, there are “D.O.- or IMG-friendly” programs, as they are known in the blogosphere, which tend to be in smaller community hospitals with lower patient volumes, older technology, and fewer resources than university hospitals. This segregation is so widespread that nationwide, USMDs make up 90 percent or more of the housestaff at over 37 percent of all internal medicine university programs and less than 10 percent of the housestaff at over 51 percent of all internal medicine community programs. Indeed, the exceptions are the integrated programs, which comprise only about 16 percent of internal medicine residency programs across the country. IMG-friendly programs also have lower American Board of Internal Medicine exam pass rates after graduation compared to USMD-dominated programs, even though international medical graduates have virtually the same average Step 1 scores prior to residency—one of the biggest predictors of Board passage—as USMDs. Thus, not only are USMDs and non- USMDs segregated during residency training; their training may not be equal, at least as measured by Board pass rates.

The distribution of USMDs and non-USMDs need not look this way, however. In fields like computer science, engineering, and physics, where highly skilled foreign workers make up significant proportions of the U.S. workforce, individuals are distributed across specialties and institutions more or less equally, with little concern for citizenship or origin of degree.

Tania M. Jenkins is a sociologist and author of Doctors’ Orders: The Making of Status Hierarchies in an Elite Profession.

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