by Kaparaboyna Ashok Kumar, M.D.
F.R.C.S., F.A.A.F.P

International medical graduates, or IMGs, make up approximately 25 percent of the U.S. physician workforce, but many people don’t know who they are, their importance in the delivery of health care in underserved areas of the United States and what processes they have to go through before practicing medicine in this country. IMGs are graduates of medical schools outside the United States, Puerto Rico and Canada that are recognized by the World Health Organization. They constitute not only physicians born in foreign countries, but also U.S. citizens obtaining medical school degrees outside the United States.

IMGs come to this country for a variety of reasons. Some come as legal immigrants by way of family immigration as children and spouses of U.S. citizens. Others come on their own in pursuit of better lives, as expert professionals, and some come to escape troubled homelands. The U.S. government welcomes them because their expertise is in short supply.

IMGs must meet stringent requirements before entrance into the United States is granted. The first stop to obtaining a residency training position here is passing a series of qualifying examinations. The Educational Commission for Foreign Medical Graduates is the agency responsible for certifying the readiness of IMGs to enter U.S. residency programs. The qualifying examination, the ECFMG examination, tests medical knowledge, as well as English proficiency. Even those physicians whose native tongue is English and those whose language of instruction was English must take the English Language Proficiency Test, since it applies to spoken English in the United States.

After successfully completing the ECFMG exam, IMGs must take the United States Medical Licensure examination. This exam evaluates medical knowledge in detail and is common for both IMGs and U.S. medical school graduates. Some residency program directors require IMGs to have significantly higher scores in the qualifying examinations than their United States counterparts for admission.

Since 1998, IMGs are required to take yet another exam, the Clinical Skills Assessment, which is administered only in Philadelphia, Penn. The CSA works to limit the entry of IMGs to the United States due to the difficulty of obtaining permission to enter the country to take the test and the affordability of the test.

This has caused tremendous hardship to those who want to come from other countries. It limits the entry of IMGs to those who can afford to pay for the test, not to mention the journey here to take the exam. This has caused a lot of concern among related circles as the process enables only an advantaged few while blocking many well-qualified candidates.

After completing all the above requirements, foreign-born IMGs have to get permission to enter the United States. They can come as exchange visitors on J1 visas or on temporary employment visas. These IMGs have to return to the country of their last permanent residence after their training, particularly the people on J1 visas.

As there is a growing need in the United States to supply physicians to underserved areas, the U.S. Department of Agriculture sponsors the J1 Visa Waiver Program, whereby foreign-born physicians can remain in the United States for three to five years after completing their education. These physicians must agree to practice in medically underserved areas.

There are several types of J1 Visa Waiver Programs active in the United States. One program, called Conrad/State 20, allows each state to sponsor 20 physicians to work in underserved areas. In the aftermath of Sept. 11, 2001, the waiver program was put on hold, but in October 2002, a proposal to expand the program passed in both the House and Senate and President Bush is expected to sign new legislation into law.

Some facts about IMGs

In 2001, of the 5,134 IMGs entering first-year residency programs, 22 percent were U.S. citizens, 39 percent were U.S. permanent residents and 32.6 percent were foreign nationals. Thus, about one-third of IMGs require some type of visa waiver program to stay in the United States.

There are conflicting reports about the supply of physicians in our country. Some studies express concern that physicians may be at a surplus in the next few decades, but others indicate a physician shortage in primary care. It is unclear whether the surplus theory applies particularly to family physicians, as many counties across the country as well as the state of Texas are designated as health professional shortage areas without an adequate number of primary care physicians. According to the National Resident Matching Program, the fill rate increased to 57.5 percent in 1992 to 90.5 percent in 1996 and then it decreased to 70.3 percent in 2001.

The percentage of post match fills that were IMGs in 2001 (47.9 percent) is more than double the percentage of IMGs that filled through the match (21.4 percent). Thus a disproportionately high number of IMGs get into the program after the match. Recent studies reveal that significant number of family practice residency programs rely on IMGs. About 50 percent of the programs had at least one IMG and about 10 percent of the programs depended mostly on IMGs.

There is a misconception amongst the U.S. medical students that the programs, which employ the IMGs, have more onerous work for the residents. Therefore they are not popular among these students. Some program directors think they cannot get state and federal funds if they employ IMGs. This is not true. Much work needs to be done to educate the medical students and the program directors to clear up these misconceptions.

According to the Robert Graham Center, the United States ranked second behind India in the top birth countries for IMGs in 1999, so many IMGs are U.S. citizens by birth. The top 10 countries of medical school training for IMGs in family practice residency are India, Montserrat, Granada, Dominica, Philippines, Mexico, Pakistan, former U.S.S.R., China and Nigeria. According to this, many U.S. citizens are going out of the country to get their medical school training.

IMGs play a very crucial role in the delivery of health care to people all over the country but most importantly to the underserved areas in both rural and urban settings. According to several studies, many U.S. counties are designated as health professional shortage areas. This is partly because many physicians, particularly U.S. graduates, tend to practice in bigger cities and not in remote areas. Thus, there is a concentration of doctors in large cities way out of proportion to the need. There is a direct correlation between poverty and inadequate medical care in this country. The same studies also indicate that IMGs are entering in a greater proportion into primary care specialties like internal medicine, family practice and pediatrics and are willing to practice in inner cities and rural towns across the country.

By recruiting IMGs with a desire to practice family medicine into residency programs in the United States, physicians with a wide range of experience, language and cultural skills will be produced, who, in turn, will serve our diverse population. This is true not only for IMGs, but also for the U.S. medical graduates graduating from programs with IMGs, as they are exposed to different linguistic and cultural backgrounds while in training.

Thus, without doubt, IMGs form an integral part of our health care system. We should consider ourselves privileged to be able to attract them to this land of opportunity and use their varied backgrounds and skills to enrich society and serve Americans, irrespective of place of residence or financial status.

Dr. K. Ashok Kumar is a professor at the family practice residency program at the University of Texas Health Center in Tyler, Texas. He is one of the first elected IMG delegates to the AAFP Congress of Delegates and he serves on the AAFP Committee on Special Constituencies. He is also secretary of the Smith County Medical Society.