Internationally trained physicians are key members of the U.S. physician workforce. The United States has not produced enough nationally educated physicians to meet the country’s health care demands for some time, and internationally trained physicians have made up for this shortfall, comprising approximately 25% of the total U.S. physician workforce. Despite a rigorous certification process, questions have persisted concerning the quality of care that these physicians provide. A new study, published in the August issue of Health Affairs and authored by a team led by FAIMER President and CEO John Norcini, examines the performance of internationally trained physicians compared to their U.S. counterparts, and addresses those concerns:
“Evaluating the quality of care provided by graduates of international medical schools” (Health Affairs, 29(8):1461-1468)
John J. Norcini, Ph.D., FAIMER President and CEO
John R. Boulet, Ph.D., FAIMER Associate Vice President for Research and Data Resources
W. Dale Dauphinee, M.D., FAIMER Senior Scholar
Amy Opalek, M.S., FAIMER Data Resource Specialist
Ian D. Krantz, M.D., Member, FAIMER Board of Directors and Chair, Educational Commission for Foreign Medical Graduates Board of Trustees
Suzanne T. Anderson, Trustee-at-Large, Educational Commission for Foreign Medical Graduates Board of Trustees
The study analyzed 244,153 hospitalizations of patients with congestive heart failure or acute heart attack in Pennsylvania from 2003 to 2006. Patients were treated by physicians who specialized in family medicine, internal medicine, or cardiology. Each physician fell into one of three groups: U.S. medical graduates, U.S. citizen international medical graduates, and non-U.S. citizen international medical graduates. The composition of physicians in the study closely matched that of the total U.S. physician workforce: Approximately 75% of the 6,113 doctors were U.S. medical graduates, with the remaining 25% educated abroad. Of the physicians educated abroad, approximately 75% were non-U.S. citizens and 25% were U.S. citizens.
The study examined both mortality rates and hospital lengths-of-stay as indicators of the quality of care that physicians provide. Among the three groups, in-hospital death rates differed significantly. Non-U.S. citizen international graduates were associated with a 16% decrease in mortality relative to U.S. citizen international graduates and a 9% decrease relative to U.S. graduates. Patients of U.S. medical graduates had the shortest hospital lengths-of-stay, while patients of U.S. citizen international graduates had the longest. The length-of-stay of patients of non-U.S. citizen international graduates was only slightly higher than that of U.S. graduates, indicating little practical difference.
These results provide a measure of confidence in the care provided by non-U.S. citizen internationally educated physicians and highlight the important contribution that they make to the U.S. health care system. As Dr. Norcini points out, “It is reassuring to know that patients of these doctors receive the same quality of care that they would receive from a physician trained in the United States.” He adds, “These findings bring attention to foreign-trained doctors and the valuable role they have played in responding to the nation’s physician shortage.”
Still, the findings concerning internationally trained U.S. citizens elicit a moment of pause. Why did these physicians fare less well in the study? The authors speculate that some of them may seek their education abroad because they were unable to enter U.S. medical schools due to lower grades and/or test scores. Alternately, the quality of education provided at some of the schools attended by these physicians may be of a lower standard than at schools attended by physicians in the other two groups. There may be other explanations as well, and additional research is warranted. Regardless, as U.S. medical schools expand enrollment to combat the shortage of home-educated physicians, some of the students who might have otherwise gone abroad may apply to medical schools in the United States. If that happens, U.S. schools will need to maintain high admission standards to ensure the quality of the physician pool. Further compounding the issue is a lack of proportionate growth in graduate training programs to complement the expansion of medical schools. As Dr. Norcini points out, “If this continues, the current physician shortages will persist and the numbers of foreign-trained doctors will likely decrease significantly.”
In addition to its findings concerning the three separate groups of medical graduates, the study also provided insights applicable to the general physician population. The authors found that in-hospital mortality rates and hospital lengths-of-stay increase with the number of years following graduation from medical school, whereas specialty board certification was associated with lower mortality and shorter hospital stays. These findings point to the need for ongoing training and periodic assessment throughout a physician’s career to maintain a high level of competence, an important consideration for all doctors, regardless of where they received their education.