Study Finds Non-U.S. Citizen International Medical Graduates Provide Same Quality of Care as Physicians Educated in the United States

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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.

The Network: TUFH Annual Meeting

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The Network: Towards Unity for Health Annual Meeting took place in Kampala, Uganda in September. FAIMER leaders were among those in attendance. John Norcini, FAIMER President; John Boulet, Associate Vice President for Research; and William Burdick, Associate Vice President for Education and Co-Director of the FAIMER Institute, presented a full-day workshop on changing student assessment. Sixteen participants from sub-Saharan Africa spent the day learning about validity, reliability, standard setting, and new methods of assessment as they considered the best ways to introduce change in their institutions. Sarah Kiguli, a 2004 FAIMER Institute Fellow and chair of the local meeting organizing committee, was elected to The Network’s Executive Council.

For more information on the conference, visit The Network: Towards Unity for Health website.

2007 AERA Annual Meeting

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The 2007 Annual Meeting of the American Educational Research Association (AERA), The World of Educational Quality, took place from April 9-13 in Chicago, Illinois. The meeting highlighted significant research around the globe to improve educational systems, address access and opportunity, and strengthen student learning and achievement. Through approximately 2,400 peer-reviewed research symposia, panels, and other scholarly sessions, some of the most important work being done across disciplines and areas of inquiry were presented and considered at the meeting. Presidents and others in the leadership of many international research associations presented to more than 1,500 international participants.

FAIMER staff presentations (with FAIMER staff listed in bold) included:

Evaluating the spoken English proficiency of international medical graduates as part of the USMLE™ Step 2 CS exam.
*Marta J. Van Zanten, John R. Boulet, Danette W. McKinley, Andre F. de Champlain

The relationship between patient satisfaction and clinical competence in a standardized patient assessment.
*Danette W. McKinley, John R. Boulet, Marta J. Van Zanten

*Presenter

FAIMER Represented at World Health Organization’s SEDCAP Planning Meeting

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John Boulet, Ph.D., FAIMER Director of Research and Data Resources, participated in the World Health Organization (WHO) sponsored meeting on strengthening educational capacity in the prevention and treatment of HIV/AIDS in five African countries (SEDCAP), May 29-31, 2006, in Gaborone, Botswana. In addition to Dr. Boulet, Professor Sam Luboga (WHO Uganda) and Dr. Dan Kayongo (University of Transkei, South Africa), both former FAIMER Institute Fellows, were in attendance.

The goal of SEDCAP is to strengthen the human and institutional resources of schools of health professionals in Botswana, Burkina Faso, Malawi, Mozambique, and Uganda. By doing this, their graduates will be better equipped to prevent and treat HIV/AIDS.

Hosted by the Department of Nursing Education of the University of Botswana, WHO Collaborating Centre, the event attracted more than 60 attendees, including deans and members of the faculty development committees in the project countries, WHO staff, partners, and donor organizations. Presentations were made to familiarize all participants with the educational capacity and performance needs of the local African institutions, and small group discussions were held aimed at delimiting the relevant local educational challenges and developing specific needs assessment measurement tools. On the final day, country teams were formed and asked to devise country-specific action plans. These detailed plans will be used to initiate the second phase of the SEDCAP project.

FAIMER Holds Symposium at 12th International Ottawa Conference

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FAIMER staff members presented on various research projects and initiatives at the FAIMER Symposium of International Medical Education Issues at the 12th International Ottawa Conference on Clinical Competence, May 20-24, 2006 in New York City. Topics included: accreditation processes throughout the world, characteristics of the world’s medical schools, migration from Africa to the United States, and immigration from South Asia. Other presentations by FAIMER staff included a workshop on the Mini-CEX conducted by John Norcini, Ph.D., FAIMER President; a workshop on building a state-of-the-art clinical skills simulation center co-presented by John Boulet, Ph.D., FAIMER Director of Research and Data Resources; and presentations at the National Board of Medical Examiners symposium, United States Medical Licensing Examination (USMLE): Performance of International Medical Graduates.

The 12th Annual Ottawa Conference was the largest Ottawa Conference to date, with over 1,000 medical school faculty, health educators, policy makers, and researchers from around the world in attendance.

Perspectives from Mendoza

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The School of Medical Sciences, Universidad Nacional de Cuyo, in Mendoza, Argentina, hosted the XI International Meeting of Medical Education on March 29-30, 2006. Organized by Dr. Ana Lía Vargas, a 2001 Fellow of the FAIMER Institute and former Institute Global Faculty Advisor, the meeting was attended by more than 40 individuals, including faculty from medical schools in Chile and Argentina. FAIMER representatives, John Boulet, Ph.D., Director of Research and Data Resources, and Marta van Zanten, M.Ed., Research Associate, also participated. Like their predecessors in 2003 and 2005, the conference centered on the assessment of clinical skills.

Dr. Boulet rated the conference as highly successful in promoting FAIMER’s mission of providing opportunities for the cross-cultural exchange of experience and expertise in the fields of physician training and assessment. Participants gave very positive feedback to the meeting organizer and expressed appreciation for the opportunity to network with each other and enhance their skills in clinical competence evaluation, as reflected in the feedback of Kristina Weil, M.D., Institute 2002 Fellow:

I traveled to Mendoza with two other faculty members from Universidad de los Andes (Santiago, Chile), who are working very hard on OSCE…and with two other Chilean medical doctors from the Medical School of Universidad del Desarrollo, where I am also teaching. It was a very good opportunity to share experiences and to promote new teaching techniques and FAIMER in Chile. All four colleagues were fascinated by the course and increased their interest in medical education. We are strongly thinking on the organization of a similar meeting in Santiago de Chile, probably next year.