Comparison of Surgical Residency Applicants from Comparison of Surgical Residency Applicants from U.S. Medical Schools with U.S.-Born and Foreign-U.S. Medical Schools with U.S.-Born and Foreign-

Born International Medical School GraduatesBorn International Medical School Graduates

Paul J. Schenarts, MD, Katie M. Love, MD, Paul J. Schenarts, MD, Katie M. Love, MD,

Steven C. Agle, MD, MPH, Carl E. Haisch, MDSteven C. Agle, MD, MPH, Carl E. Haisch, MD

Division of Surgical EducationDivision of Surgical Education

Department of SurgeryDepartment of Surgery

East Carolina UniversityEast Carolina University

IntroductionIntroduction

• Impending physician shortage

• Evolving crisis in access to emergency surgical care and aging population

• One solution = increase number of international medical graduates (IMG)

IntroductionIntroduction

International medical graduates’ contributions:

• More frequently provide care to underserved and rural populations1

• Contribute to surgical research– 21% of principal investigators of NIH research projects2

• Account for 19% of U.S. medical school faculty2

• Enter academic surgery at rates comparable to US graduates3

1.Howard et al, 20062. Alexander et al, 2007

3. Arannha, 1998

ProblemProblem

The perception of the quality of IMGs’ educational preparation and performance is variable

Negatives:– Discrimination by program directors1

– Diminished reputation – Cultural and communication issues– Higher failure rates on the Board Exam2

– 1,935 different medical schools

Positives:– Several programs actively seek IMGs

1. Moore & Rhondenbaugh, 20022. Norcini, et al, 2006

PurposePurpose

Compare applicant characteristics of US medical school graduates with US-born and foreign-born international medical graduates.

MethodsMethods

• IRB and GME approval

• Retrospective analysis

• All 2007 ERAS applicants to our general surgery residency

• Definition of US graduates– Allopathic and osteopathic medical schools– Foreign-born US graduates

• Graduates from outside the US, were considered IMGs

• Assignment to US-born or foreign-born IMG groups was

based on self reported country of birth

MethodsMethods

Data points:

• Demographic data- Age - Visa status- Gender - Citizenship- Couples match - Current residence

• USMLE performance

• Number of scholarly works (presentations, publications)

• Attainment of advanced degrees

• Employment history since medical school graduation

MethodsMethods

• Analysis: T-test and Chi square

Results: DemographicsResults: Demographics

U.S. Graduates U.S.-Born IMG Foreign-Born IMG Applicants: 166 85 321

Age (Years): 28.9 3.2 29.9 3.5* 33.0 6.6‡

Male Gender: 70% 80% 86%‡

U.S. Citizenship: 97% 100% 15%†

Living in the U.S.: 100% 100% 79%‡

Couples Match: 3.6% 1.2% 1.9%

Data presented as mean standard deviation or percent.

Statistical comparisons are with U.S. graduates only. * p<0.05, † p<0.01, ‡ p< 0.0001

Results: Visa types for Foreign-Born IMGsResults: Visa types for Foreign-Born IMGs

Permanent Resident 28%

B-1 17%

U.S. Citizen 15%

B-2 10%

J-1 9%

F-1 7%

Other 5%

H-1B 4%

H-4 2%

EAD 1%

Refugee/Asylum 1%

TN NAFTA 1%

Results: Medical School LocationResults: Medical School Location

U.S. Graduates U.S.-Born IMG Foreign-Born

IMG United States (100%) Caribbean (70%) South Asia (29%)

South Asia (9%) Middle East (16%)

Central America (6%) Caribbean (9%)

Middle East (5%) China (8%)

Eastern Europe (3%) Central America (7%)

South America (3%) Eastern Europe (7%)

South Pacific (2%) South America (5%)

Africa (1%) Africa (4%)

United Kingdom (1%) Central Asia (3%)

Russia (3%)

United Kingdom (2%)

Western Europe (2%)

Southeast Asia (2%)

Mediterranean (1%)

Northern Europe (1%)

South Pacific (1%)

Results: USMLE PerformanceResults: USMLE Performance

U.S. Graduate U.S.-Born IMG Foreign-Born IMG

USMLE step 1: 206 20 200 26 202 28

Multiple attempts: 9% 20%† 24%‡

USMLE step 2: 213 23 201 29† 203 31†

Multiple attempts: 4% 22%‡ 19%‡

Data presented as mean standard deviation or percent.

Statistical comparisons are with U.S. graduates only. * p<0.05, † p<0.01, ‡ p< 0.0001

Results: Pre-application Experience

U.S. Graduates U.S.-Born IMG Foreign-Born IMG

Yrs since graduation: 0.3 0.7 1.5 1.9‡ 7.7 6.8‡

Advanced degree: 11% 13% 19%†

(Masters / PhD) (84% / 6%) (91% / 9%) (77% / 23%)

Scholarly works: 1.7 3.0 0.9 2.0† 3.9 8.4†

Jobs since graduation: 0.3 0.5 2.2 2.2‡ 5.1

3.9‡

Data presented as mean standard deviation or percent.

Statistical comparisons are with U.S. graduates only. * p<0.05, † p<0.01, ‡ p< 0.0001

Results: Most Common Jobs Since GraduationResults: Most Common Jobs Since Graduation

U.S. Graduates U.S.-Born IMG Foreign-Born IMG

18% Prelim Surgery15% Research 45% International Surg

2% Research 13% Prelim Surgery 44% Research

2% Other medicine 13% Observership 40% Other medicine

38% Observership

15% Prelim Surgery

13% Other medicine

12% Tech / assistant

Discussion: US-Born IMGs compared to US graduatesDiscussion: US-Born IMGs compared to US graduates

Positive attributes:• Slightly older and hold more advanced degrees• Research experience • Clinical experience in prelim surgery or medicine• Similar USMLE Step 1 scores

Negative attributes:• Required multiple attempts to pass Step 1 and 2• Significantly lower Step 2 scores• Fewer scholarly works

Discussion: Discussion: Foreign-Born IMGs compared to US graduates Foreign-Born IMGs compared to US graduates

Positive Attributes:

• Hold more advanced degrees, particularly more PhDs• Similar USMLE Step 1 scores• More scholarly activity• Greater research experience• Significantly more clinical experience in international

surgery or other medical fields

Discussion: Discussion: Foreign-Born IMGs compared to US graduates Foreign-Born IMGs compared to US graduates

Negative attributes:

• Older• Significant time between graduation and application• Lower USMLE Step 2 scores• Required multiple attempts to pass Step 1 and 2

Discussion:Discussion:

• While most IMGs are living in the U.S., their medical schools are often located in areas of the greatest health care need

• Draining these areas of the best and brightest to meet U.S. needs may have ethical, social and political repercussions

Discussion: LimitationsDiscussion: Limitations

• Retrospective• Self-reported data• Moderate size, single institution• Rural location

• Did not determine which factors predict success

Conclusions:Conclusions:

• IMGs offer many attributes program directors and selection committees favor

• Older applicants, who graduated several years ago, and have trouble passing standardized tests may have a difficult time

• IMGs may help solve the shortage of physicians, however, residency programs will need to address communication, cultural differences, and test taking skills