Do Foreign Medical Graduates “Doctor” Better?
Yes, according to a study in today’s Health Affairs. (The full text of the study is available only to subscribers, but Kaiser Health News Daily has a good summary of its findings and links to other news reports.)
The study compares inpatient death rates and lengths of stay for patients with congestive heart failure or acute myocardial infarction when provided by U.S. citizens trained abroad, citizens trained in the United States, and non-citizens trained abroad. Treatment was provided by internists, family physicians, or cardiologists. The differences were striking, according to the authors:
“Our analysis of 244,153 hospitalizations in Pennsylvania found that patients of doctors who graduated from international medical schools and were not U.S. citizens at the time they entered medical school had significantly lower mortality rates than patients cared for by doctors who graduated from U.S. medical schools or who were U.S. citizens and received their degrees abroad.”
It also found that board certification was positively associated with lower mortality and lengths of stay. Years in practice since graduation are associated with poorer outcomes. Self-designated cardiologists had higher mortality rates but lower lengths of stay than self-designated general internists and family physicians.
John Norcini, the study’s co-author, tells Bloomberg News that “economics may help explain the gap in patient outcome.” Because of lower pay relative to other specialties “primary care may not be getting the best and the brightest from U.S. medical schools,” said Norcini. “Foreign students see primary care as a gap that they can fill and a way to practice medicine here.” He calls non-citizen international medical graduates (IMGs) the “cream of the crop” because the ones who make it through are “highly desirable and motivated.”
The study, if supported by other research, could have important public policy implications. One is that the that the public should have more confidence that the care provided by non-citizen IMGs (in general) is at least as good as U.S. citizens trained here, at a time when IMGs are likely to remain a critical component of a primary care workforce in shortage.
The idea that the U.S. is depending on the “cream of the crop” of non-citizen IMGs though, will add to concerns about a “brain drain” from less developed nations that have an even greater need for well-trained physicians. This concern was examined by the American College of Physicians in a 2008 policy monograph, which “cautions that the nation should not rely on IMGs alone to solve the shortage of physicians in the United States and that balance must be achieved between respecting the freedom of IMGs to migrate and fulfilling the needs of both home and host countries.”
The study also speaks to the need for fundamental changes in payment and delivery models to once again attract the “best and the brightest” to internal medicine.
Today’s questions: What is your reaction to the finding that non-citizens trained abroad do better than U.S. citizen IMGs or U.S. trained physicians? That board certification is positively associated with better outcomes, while years of practice since training are associated with poorer outcomes? What should policymakers do with this information?
*This blog post was originally published at The ACP Advocate Blog by Bob Doherty*