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The International Medical Graduate Supply Offers a Unique Solution to the Expected Physician Shortage Through a
Standardized Curriculum and The New Wave of Accountability and Efficiency in Health Care Reform

Author: Sajeet Sohi MD

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With the passing of The Patient Protection and Affordable Care Act the primary care provider
shortage has been placed into the spotlight. There are several well publicized factors that have
been attributed to the situation ranging from reimbursement, lifestyle, to distribution of
resources.1-3 The AAMC has stated that by 2025 the physician shortage will reach 130,600 of
which 64,800 is the expected specialist shortage.4 For the sake of comparison, the former figure
is equivalent to the population of Fullerton, CA and the later comparable to the population of
Portland, ME.5 In the same report, the AAMC recommends Congress to increase residency
positions by 15% and reverse the current freeze on Medicare funded positions since 1997.

Traditionally, discussions regarding the physician shortage and primary care gap have focused
on the attitudes, career decisions, and supply of US medical students.6-9 An alternative approach
is to increase the International Medical Graduate supply stream. The IMG community now
represents 25% of practicing physicians and it has been shown that IMGs are more likely than
their US graduate counterparts to train in a PCP residency, become primary care physicians, and
practice in a rural area.10- 12 An increased physician supply alone will not be able to fill the
expected shortage, especially due to growing burden of chronic disease.13 Increasing the roles of
nurse practitioners and physicians assistant will become important trends.14,15 Optimizing the
IMG physician supply chain should be considered an integral part of the solution. A two pronged
approach involves a standardized basic sciences curriculum and utilizing new organizations
introduced in health care reform to increase the physician supply.

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According to the AAMC, in 2008 there were 25,818 individuals who entered GME training and
of those 7,462 were IMGs. The IMG population included 2,294 US Citizens from international
schools and 1,813 US Citizens from Caribbean medical schools.16

Nation 2004 2007 % Change

India 1786 1787 No change
Dominica 343 451 + 31.5
Pakistan 496 447 - 9.9
Grenada 365 426 + 16.7
Netherland Antilles 251 347 + 38.2
Table 1: Top Five Nations Producing IMGs in First Year GME Training. Source: AAMC

There are challenges facing the IMG community including: obtaining appropriate work visas, the
ethical implications of these individuals leaving their homeland, integration into the American
health care system and culture, and discrimination in the residency selection process.17-19 IMGs
and US medical graduates may have different views on their personal and professional goals as
shown in an analysis of six Baltimore internal medicine residencies.20 There is also concern
about the outcomes of Caribbean medical students.21-23 The Government Accountability Office
has indicated that from 1998 - 2008 US Citizens attending foreign medical schools received $1.5
Billion in Federal Loans and it has been difficult to independently verify the outcomes of the
students despite visiting five established foreign medical schools.24 In addition, the physician
shortage models may be inadequate or have overestimated the expected shortage.25

What are the outcomes of patients treated by IMGs compared to US graduates? This was
analyzed in a review of 244,153 hospitalizations due to congestive heart failure and acute
myocardial infarction in Pennsylvania, which found that there was no significant difference in
patient mortality between those patients who were treated by IMGs compared to all US
graduates.26 Once an individual has successfully completed the required USMLE series of
examinations and has received their GME training. There is no distinction between where an
individual has received their medical school training and patient outcomes.


   
  

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Medical schools in North America are generally structured into four year programs, but there are
three year programs which attempt to promote primary care careers.27,28 Typically, the first two
years are an introduction to the basic sciences and the last two years being the clinical clerkships.
Students usually attempt USMLE Step 1 after their second year of basic sciences and both
USMLE Step 2 Clinical Knowledge and Clinical Skills during their third to fourth year. IMGs
must pass the above USMLE examinations and be graduates of a licensed medical school to
become ECFMG certified and be eligible for an ACGME approved residency. Completing the
USMLE series of examinations is a significant obstacle and this may be due to language
comprehension, inadequate medical school education, or problems with standardized testing.29-32

USMLE Step 1 USMLE Step 2 CK USMLE Step 2 CS

US Citizens (IMG) 55% 69% 79%
Foreign Citizens (IMG) 67% 80% 68%
Total (IMG) 63% 78% 71%
US/Canadian Medical Students 91% 96% 97%
Table 2: USMLE Pass Rates for IMG,US, and Canadian Medical Students.
Source: ECFMG 2009 Annual Report33 and NBME 2009 Annual Report34

The USMLE pass rates may be seen as a validation that certain students of ³Offshore Medical
Schools´ are individuals who may not have the capacity or competence to be a quality care
provider. An alternative viewpoint is that we have a population of individuals who have hit a
roadblock due to a non-standardized medical school curriculum or medical education not tailored
to the USMLE content.

It has been noted recently that using USMLE Step 1 and Step 2 scores as a method for resident
selection is neither structured, coherent, or evidence based.35 This may indicate that a more
effective testing method is required to properly assess medical student¶s aptitude and also that
residency selection should head to a more comprehensive review of an individual¶s application.
Examinations alone are not used in resident selection and the top four factors to select an
individual to interview for a residency program according to the 2010 NRMP Program Director
Survey includes: USMLE Step 1 score, letter of recommendation in specialty, the personal
statement, and grades in required clerkship.36 Once an individual is selected for an interview they
could potentially match into the program.




 

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The classic report by Abraham Flexner in 1910, m

 
   
  


 has helped shaped US medical school education for the past century. The report
highlighted significant deficiencies in medical schools, in retrospect; many institutions that are
highly respected today admitted students a century ago who did not even complete high school.37
Today these institutions are at the forefront of medical innovation. We are moving towards
another seminal event in medical education with the recent announcement by ECFMG that
starting in 2023 an individual applying for ECFMG certification must graduate from a medical
school that has been approved by a similar criteria established for U.S. medical schools by the
LCME or World Federation for Medical Education.38

Medical education and graduate training must adapt to the changing environment. A recent
review details the need for adapting the realities of the global world into medical education and
the challenges upcoming for health care systems: epidemiological and demographic transitions,
professional differentiation, population demands, and technological innovation.39

Alternative medical education techniques including internet based medical education is an

effective tool if it engages the student and offers a value-added teaching experience.40 With this
type of foreword thinking George Washington University has recently announced an online high
school.41 The natural progression of the idea is the eventual creation of an internet based medical
school.

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To create an enhanced supply of physicians the medical educational process must offer medical
students a fair playing field to succeed. The establishment of a standardized basic sciences
curriculum instituted from the NBME, ECFMG, or a new organization would allow uniform
preparation across the spectrum of applicants. This group would be responsible for creating a
series of guidelines, textbooks, and electronic media with the expected relevant information that
would be presented in the USMLE examinations. This would not be intended to replace a
school¶s curriculum, rather to highlight what will be expected on the examinations. Over time we
would see which type of teaching methods offer the best outcomes. The project would be funded
by a onetime fee from each student in a licensed LCME or ECFMG associated institution.

A standardized curriculum should be seen in contrast to commercial USMLE preparation courses

which have been found to be ineffective .42-44 Since students and educators would be well aware
of the expectations required from the organizing body. Medical schools around the world could
integrate exam preparation into the basic sciences and clinical clerkship experiences. This
proposal could possibly increase the pool of qualified individuals for GME programs and is an
effective method of utilization existing medical education facilities without significant
infrastructure costs.

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The rate limiting step to produce physicians remains the number of residency positions. In fact,
in the 2010 residency matching process according to the NRMP there were only 0.75 residency
positions per applicant, thus 25% of applicants are automatically denied training positions.

Year U.S. Senior U.S. IMG Non- U.S. Others All

IMG Applicants
1990 93.3 55.6 59.7 56.0 83.7
2000 93.9 51.4 38.5 61.3 73.4
2010 93.3 47.3 39.8 60.2 71.2
Table 3: PGY1 Match Rates. Source: NRMP Results and Data 2010 Main Residency Match45

The long term trends indicate that the match rates for IMGs have been falling while U.S. senior
match rates have remained stable. With 15 medical schools in the nation either recently opened
or in the early stages of LCME accredition46; it will only serve to tighten the limited supply of
residency positions. The new health care legislation will require a review of the entire GME
system to adapt to the changing landscape.47

The underlying theme of health care reform is to deliver care in an efficient and effective
method. With this mindset we have the opportunity to integrate increased graduate medical
education positions within the framework of providing cost effective care to an expanded insured
population. The Centers for Medicare and Medicaid Innovation (CMMI) plans for a dialogue
which aims for better care for individuals, coordinating care to improve healthcare outcomes for
individuals, and community care models.48 Accountable Care Organizations (ACO) aim to
improve the quality of care and reduce unnecessary costs to Medicare beneficiaries.49 Healthcare
Innovation Zones (HIZ) will help redesign academic medical centers to focus on healthcare
delivery, medical education, and research. HIZs could possibly allow medical school education
and residency training to adapt to the new realities.50 The CMMI will be integral as Medicare
and Medicaid through the direct and indirect medical education payments is the primary source
of graduate medical education funding.51,52 Together the CMMI, ACO, and HIZ have the
potential to pool resources and increase GME positions.

   

Massachusetts is seen as an early barometer of health care reform as the state adopted a universal
care law in 2006. The early returns on the states reform has been impressive as Massachusetts
has the lowest uninsured population in the nation and there has been an increased access to
health care.53 Critiques of the reform include the financial responsibility of the state, unequal
distribution of providers, and an inadequate primary care physician supply.54 It is apparent that
although universal care has the potential to increase access to health care we must address the
lack of patient care providers.
The projected physician shortage estimates will become a barrier to access as seen in
Massachusetts. The US medical school supply is running at maximum capacity and efficiency
thus international medical graduates are uniquely suited to be integral players in the solution.
Since these individuals are more likely to become primary care providers and this can be
accomplished through a standardized medical school education and increased graduate medical
educational positions with the leadership of the CMMI, ACO, and HIZ. Although these
proposals may lack specific details and be seen as the idealistic thoughts of a young physician in
training, we can use this opportunity to explore new avenues to produce the next generation of
physicians.
About The Author: Sajeet Sohi is a recent International Medical Graduate

Medical School: Aureus University School of Medicine, Aruba (2011)

Undergraduate: University of Toronto, Hons. BSc. (2007)

Contact: Sajeet Sohi

sajeetsohi@sohimd.com

Conflicts of Interest/Disclosures: None

Keywords: USMLE, international medical graduate, graduate medical education, primary care
provider, physician shortage, residency
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