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International Medical Graduates: A Possible Solution to the Expected Physician Shortage

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 Introduction 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. International Medical Graduates - Challenges and Opportunities 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. Completing The USMLE Examinations is an Obstacle to an Increased IMG Graduate Medical Education Applicant Pool 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 US Citizens (IMG) 55% 69% Foreign Citizens (IMG) 67% 80% Total (IMG) 63% 78% US/Canadian Medical Students 91% 96% Table 2: USMLE Pass Rates for IMG,US, and Canadian Medical Students. Source: ECFMG 2009 Annual Report33 and NBME 2009 Annual Report34 USMLE Step 2 CS 79% 68% 71% 97%

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. Medical School Education is at Crossroads - The Next ³Flexner´ Moment The classic report by Abraham Flexner in 1910, Medical Education in the United States and Canada 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. Proposal #1: Standardized Basic Sciences Medical School Education 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. Proposal #2: The Center for Medicare and Medicaid Innovation, Accountable Care Organizations, and Healthcare Innovation Zones as a Method to Increase GME Positions 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 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. Conclusion 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. U.S. Senior U.S. IMG

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 Conflicts of Interest/Disclosures: None Keywords: USMLE, international medical graduate, graduate medical education, primary care provider, physician shortage, residency

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