International Medical Graduates Update on A Diversified Physician

International Medical Graduates: Update on A Diversified Physician Workforce SELIM KRIM, MD ASSISTANT PROFESSOR OF MEDICINE DIVISION OF GENERAL INTERNAL MEDICINE TEXAS TECH UNIVERSITY HEALTH SCIENCES CENTER

Where I am from

Algeria/Location

Where I was born

Algeria/History 500, 000 and 700, 000: Homo erectus 10, 000 BC: Berbers 1000 BC: Numidia 200 BC: Part of the Western Roman Empire 300 AD: Part of the Byzantine Empire 800 AD: Muslim Arab Armies arrive 1510: Spain takes control 1516: Part of Ottoman Empire 1830: France invades Algeria 1954: Algerian War of Independence 1962: Independence of Algeria

Algeria Country Name: People's Democratic Republic of Algeria Government type: Republic Independence: July 5, 1962 Population: 34, 178, 188 Age: 26. 6 years (median), 65 -0 ver represent 5% of total Population Ethnic groups: Arab-Berber 99%, European less than 1% Languages: Arabic, French, Berber Religions: Sunni Muslim (state religion) 97%, Christian and Jewish 3%

Algiers The White

Our Lady of Africa

Our Lady of Africa

Ketchaoua Mosque

My Journey Paris Lubbock Pittsburgh Algiers

International Medical Graduates

Definitions IMGs are physicians who have completed their medical education outside the U. S. or Canada. IMGs consist of: Foreign nationals on special visa status (eg. J 1 or H 1 B) U. S. citizens or permanent residents who graduated from foreign medical schools

Where are they coming from? Zoghbi, W. A. et al. J Am Coll Cardiol 2004; 44: 245 -251

The Educational Commission for Foreign Medical Graduates (ECFMG) “ Through its program of certification, the Educational Commission for Foreign Medical Graduates (ECFMG®) assesses the readiness of international medical graduates to enter residency or fellowship programs in the United States that are accredited by the Accreditation Council for Graduate Medical Education (ACGME). ”

ECFMG Certification Pass the USMLE: Medical Science Examination Step 1 Clinical Skills Assessment Step 2 (CS) Clinical Knowledge Assessment Step 2 Must pass all exams within a 7 year period! ECFMG Verification of medical diploma with medical school

The NRMP “Match” • The National Resident Matching Program (NRMP) is a private, not-for-profit corporation established in 1952 to provide a uniform date of appointment to positions in graduate medical education (GME). • Each year, the NRMP conducts a residency match that is designed to optimize the rank ordered choices of students and program directors.

How many IMGs Apply for PGY 1 position? U. S. NRMP, Match results. 2007

How many IMGs Obtain a PGY 1 Position? U. S. NRMP, Match results. 2007

Challenges

Costs The USMLE: Medical Science Examination Step 1= $ 710 Clinical Skills Assessment (Step 2 CS)= $ 1200 Clinical Knowledge Assessment (Step 2 CK)= $ 710 Interviews and travel: Program Applications: $ 2000 Cost of travel for step 2 CS: $1000 -$2000

Visas Immigration Laws • Can affect training of IMGs and chances of joining the workforce • Increasingly pose obstacles for international travel for IMGs and their families Employment • • Primarily related to visa status J-1 visa holders are at increasing risk of not finding waivers, particularly after Sept. 11 th

Visas (Non-Clinical Visa Programs) • J-1 Research- 5 years maximum potential duration (Caution: 2 -year rule may be attached) • H-1 B – 6 years maximum duration • NAFTA – Canadian & Mexican nationals only Universities, medical schools and research institutions may offer visa assistance for research activities

Visas (Visa Programs for Clinical Training) J-1 ECFMG (Educational Commission for Foreign Medical Graduates) - 7 years maximum potential duration Caution: 2 -year home rule is attached. • • H-1 B – 6 years maximum duration Requires all 3 Steps of USMLE

Country of Medical School Distribution Patterns of Origins and Destinations Demographic Characteristics http: //www. fammed. washington. edu/CHWS/

http: //www. fammed. washington. edu/CHWS/

Distribution of IMGs in The U. S. in 2001, by County http: //www. fammed. washington. edu/CHWS/

http: //www. fammed. washington. edu/CHWS/

http: //www. fammed. washington. edu/CHWS/

Who are the patients of international medical graduates? • Race/Ethnicity • Expected source of payment • Characteristics of patient’s neighborhoods Who are international medical graduates? Where do international medical graduates practice?

NCHS Data Brief ■ No. 13 ■ February 2009 Office visits by Patients RaceEthnicity NCHS Data Brief ■ No. 13 ■ February 2009

Office visits by patients’ primary Expected sources of payment NCHS Data Brief ■ No. 13 ■ February 2009

Characteristics of patient’s neighborhoods NCHS Data Brief ■ No. 13 ■ February 2009

IMG vs. USMG By Race/Ethnicity NCHS Data Brief ■ No. 13 ■ February 2009

Where do IMG they practice? NCHS Data Brief ■ No. 13 ■ February 2009

The purpose of this pilot project was to assess IMG perceptions in two major policy areas: (a) IMG impact on U. S. healthcare (b) IMG impact on countries of origin

Impact on U. S. healthcare S. Agrawal. OPUS 12 Scientist 2008 Vol. 2, No. 1

Impact on Countries of Origin S. Agrawal. OPUS 12 Scientist 2008 Vol. 2, No. 1

Impact on Countries of Origin S. Agrawal. OPUS 12 Scientist 2008 Vol. 2, No. 1

Conclusion • IMGs represent about a quarter of the entire physician workforce • India, the Philippines, Mexico and the Republic of Korea remain the leading countries of origin of IMGs • There have been consistent patterns of IMG origin countries and destination states • International medical graduates are more likely to practice in primary care shortage areas • They are also more likely to have more Medicaid patients and minorities

Conclusion • U. S. health care system continues to rely on international medical graduates to address primary care physician shortage outside of urban metropolitan statistical areas • However our system may face challenges if the future supply and use of international medical graduates are affected by changes in visa policy and other programs affecting physician supply • New policies may be needed in the future

International Leaders Huda Zoghbi, MD Lebanon Andreas Gruntzig, MD Germany Salim Yusuf, MD India Elias Zerhouni, MD Algeria Valentine Fuster, MD, Ph. D Spain

“Share our similarities, celebrate our differences” M. Scott Peck, MD

Thank you