Discovering Patterns and Disseminating Knowledge

Meaningful research on the many issues that affect health care is critical to informing the policy decisions that can lead to better health. An important component of this research is to understand how the educational experiences and migration patterns of international medical graduates impact the health of the world's populations. The characteristics of medical education and prevailing health care workforce issues are significant influences on health outcomes in regional health care systems. An understanding of the dynamic among medical education, workforce issues, and the quality of health care is essential to improving medical education and, ultimately, the health of all people.

The goals of FAIMER's Research Center are to investigate and understand these issues and to share its results broadly with researchers, physicians, students, credentialing and licensing organizations, policy makers, and the public. The wide availability of such resources will assist in the efforts to improve medical education and health care that are underway worldwide.

Analyzing Existing Data Resources

Developing high quality data resources on international physicians is an important component in understanding physician workforce issues and how they affect the quality of health care. FAIMER's Data Resources Center has worked to integrate a variety of health care provider databases, including the American Medical Association's Physician Masterfile, GMETrack, and ECFMG Certification data on international physicians, to form a larger resource on these physicians in the United States. Linking these data sources makes it possible to explore in detail the practice patterns of international physicians and the role they play in the U.S. health care system.

Building on this success in developing a more comprehensive data repository on international physicians in the United States, it is possible to explore development of a corresponding data resource on physicians in other countries. To accomplish this goal, FAIMER staff will need to determine the availability and utility of health care provider data in other countries. Where available and workable data exists, the experiences gained in developing U.S. physician resources can be used to verify, integrate, and combine these data in ways that support a better understanding of the global physician network. The ultimate goal of such an endeavor would be to develop an international physician workforce data repository that could be shared among interested researchers.

Based in part on analyses of linked data sources on international medical graduates (IMGs) in the United States, the Research Center performed a number of studies in 2004, and the resulting manuscripts have been submitted for publication. These studies include:

• Citizens of the United States who Graduated from Medical Schools Outside the United States and Canada (1983-2002) — This study provides a general, descriptive overview of physicians, both U.S. and non-U.S. citizens, who obtained their medical diplomas outside the United States and Canada. Throughout the 20-year period covered by the study, U.S. citizens comprised a sizeable portion of IMGs. In recent years, the percentage of U.S. citizens certified by ECFMG rose to approximately 25% of IMGs certified in those years. As a group, they were more likely to attend medical school in Central America or the Caribbean, and their growth of recent years is appreciable in the number of U.S. citizens graduating from schools in Grenada and Dominica. While there has been a gradual decline in the number of U.S. citizens graduating from medical schools in Europe, the number graduating from medical schools in India has risen.
• The International Medical Graduate Pipeline: Recent Trends in ECFMG Certification — By describing the characteristics of IMGs pursuing ECFMG Certification over the past 25 years, this study attempts to describe the eventual composition of this important cohort of the U.S. physician workforce. The study describes trends relating to the overall volume of physicians, proportion of U.S. citizen and female physicians, and other characteristics, such as age. The study concludes by discussing the potential implications of these trends for the U.S. health care system, where IMGs play a significant role.
• International Medical Graduates in Graduate Medical Education Programs: Recent Trends — The number of IMGs participating in graduate medical education (GME) programs in the United States is significant, representing approximately 27% of the total GME population in 2003-2004. This study provides an overview of IMGs who entered U.S. residency programs from 1995-2003. The study suggests that, by analyzing whether IMGs obtain GME positions, where these positions are located, and what specialties are most commonly pursued by IMGs, predictions can be made regarding the future composition and demographics of this important group in the U.S. physician workforce, and that such analyses will benefit health care workforce planning, including geographical and specialty needs.
• Accreditation of Undergraduate Medical Education Programs: Practices in Nine Developing Countries — Accreditation of undergraduate medical education programs is practiced in many countries, but information from developing countries is sparse. This study describes and compares the medical program accreditation systems in nine developing countries - Argentina, India, Kenya, Malaysia, Mongolia, Nigeria, Pakistan, the Philippines, and South Africa - which range from high to low in the United Nations Human Development Index, in order to provide insights into accreditation practices in the developing world as compared with the United States. The factors considered include the existence of defined criteria and procedures, how recently accreditation was introduced, whether it was established by government agencies or private organizations, whether accreditation is mandatory, and the implications of non-compliance.

Creating New Data Resources

Designing survey instruments to create new data resources and analyzing their results is an important component of the Research Center's work. In conducting these activities, the Research Center supports work in FAIMER's other areas of activity, creating educational opportunities for medical educators and tracking medical education.

FAIMER's surveys of former Fellows and their mentors, begun in 2003, assist in evaluating the efficacy of the fellowship programs. Gathering information about the fellowship experience and its benefits, and the extent to which the goals of the programs are being met, is essential to ensure ongoing improvement in FAIMER's offerings for medical educators.

To verify and enhance the information available through its directories on medical education worldwide, FAIMER research staff initiated two additional surveys in 2004.

• In November, surveys were distributed to more than 100 ministers of health and/or education internationally. The ministers were surveyed concerning medical education, admission requirements, accreditation, and medical licensure in their countries.
• In December, staff of the Research Center began the process of surveying more than 1,600 medical schools. The survey, which emphasizes teaching and evaluation methods, requests information on program offerings for medical students, organization of the curriculum, opportunities for students in both required and elective experiences, ways in which instruction commonly occurs in preclinical and clinical coursework, and evaluation methods. By the end of February 2005, more than 100 schools had responded.

Collaborative Research

Many organizations and interested investigators have approached FAIMER to discuss potential collaborative research projects. These include the Association of American Medical Colleges (AAMC), the American Medical Association, U.S. Department of Health and Human Services, centers for workforce studies, health research centers, and international medical councils and colleges of medicine. Staff members of the FAIMER Research Center have met with representatives from many of these organizations and, jointly, have begun the task of defining specific research objectives.

During 2004, FAIMER and AAMC continued their collaboration to study the educational experiences of U.S. citizens who graduate from international medical schools. This group is of particular interest because nearly all U.S. citizen IMGs seek to practice medicine in the United States after completing graduate training, and the results should assist those responsible for health care policy and graduate medical education in the United States.

The study, which is being conducted and funded jointly by FAIMER and AAMC, entails identifying those international medical schools with the largest numbers of U.S. citizen graduates and gathering information about the schools' educational content, methods, and assessment. The study will conclude with analysis and dissemination of the results through multiple venues. The study, which during 2004 was in its data collection phase, is expected to span two to three years.

A number of organizations and individuals have contacted FAIMER to explore other workforce issues related to IMGs in the United States. These issues include the use of waivers of the two-year home country physical presence requirement associated with the J-1 visa, a non-immigrant visa commonly used by IMGs to participate in U.S. graduate medical education and training programs. There is also interest in more specifically delineating the practice patterns and practice locations of all IMGs within the United States.

FAIMER has also partnered with international groups to investigate specific regional issues. In collaboration with a group of current and former Institute Fellows, the Foundation has embarked on a study of the status of, and factors related to, physician migration within and from Africa. With the help of researchers in other parts of the world, FAIMER is beginning a study of medical education in India, focusing on the potential positive and negative impact of medical migration on the countries that receive physicians from Indian medical schools.