Prevalence of International Medical Graduates From Muslim-Majority Nations in the US Physician Workforce From 2009 to 2019.

Importance: Historically, the US physician workforce has included a large number of international medical graduates (IMGs). Recent US immigration policies may affect the inflow of IMGs, particularly those who are citizens of Muslim-majority nations. Objectives: To provide an overview of the characteristics of IMGs from Muslim-majority nations, including their contributions to the US physician workforce, and to describe trends in the number of applications for certification to the Educational Commission for Foreign Medical Graduates between 2019 and 2018, both overall and for citizens of Muslim-majority nations. Design, Setting, and Participants: This cross-sectional study, which included 1 065 606 US physicians listed in the 2019 American Medical Association Physician Masterfile and 156 017 applicants to the Educational Commission for Foreign Medical Graduates certification process between 2009 and 2018, used a repeated cross-sectional study design to review the available data, including country of medical school attended, citizenship when entering medical school, and career information, such as present employment, specialty, and type of practice. Exposures: Country of citizenship when entering medical school. Main Outcomes and Measures: Physician counts and demographic information from the 2019 American Medical Association Physician Masterfile and applicant data from the Educational Commission for Foreign Medical Graduates from 2009 to 2018. Results: Of 1 065 606 physicians in the American Medical Association Physician Masterfile, 263 029 (24.7%) were IMGs, of whom 48 354 were citizens of Muslim-majority countries at time of entry to medical school, representing 18.4% of all IMGs. Overall, 1 in 22 physicians in the US was an IMG from a Muslim-majority nation, representing 4.5% of the total US physician workforce. More than half of IMGs from Muslim-majority nations (24 491 [50.6%]) come from 3 countries: Pakistan (14 352 [29.7%]), Iran (5288 [10.9%]), and Egypt (4851 [10.0%]). The most prevalent specialties include internal medicine (10 934 [23.6%]), family medicine (3430 [7.5%]), pediatrics (2767 [5.9%]), and psychiatry (2251 [4.8%]), with 18 229 (38.1%) practicing in primary care specialties. The number of applicants for Educational Commission for Foreign Medical Graduates certification from Muslim-majority countries increased from 2009 (3227 applicants) to 2015 (4244 applicants), then decreased by 2.1% in 2016 to 4254 applicants, 4.3% in 2017 to 4073 applicants, and 11.5% in 2018 to 3604 applicants. Much of this decrease could be attributed to fewer citizens from Pakistan (1042 applicants in 2015 to 919 applicants in 2018), Egypt (493 applicants in 2015 to 309 applicants in 2018), Iran (281 applicants in 2015 to 182 applicants in 2018), and Saudi Arabia (337 applicants in 2015 to 163 applicants in 2018) applying for certification. Conclusions and Relevance: Based on the findings of this study, the number of ECFMG applicants from Muslim-majority countries decreased from 2015 to 2018. The US physician workforce will continue to rely on IMGs for some time to come. To the extent that citizens from some countries no longer seek residency positions in the US, gaps in the physician workforce could widen.

The Implications of the Current Visa System for Foreign Medical Graduates During and After Graduate Medical Education Training.

The current and projected deficit in the physician workforce in the US is a challenge for primary care and specialty medical settings. Foreign medical graduates (FMGs) represent an important component of the US graduate medical education (GME) training pathway and can help to address the US physician workforce deficit. Availability of FMGs is particularly important to the internal medicine community, as recent data demonstrate that internal medicine is the specialty with the highest number of FMGs. System-based and logistical inefficiencies in the current US visa system represent significant obstacles to FMG trainees and have important psychological, emotional, and logistical consequences to FMG engagement and participation in US GME training and in the post-training workforce. In this article, we review the contemporary structure, process, and challenges of obtaining a visa for GME training. The H1B and J1 visa programs are compared and contrasted, with an emphasis on logistical specifics for FMG GME trainees and training programs. The process of and options for J1 visa waivers are reviewed. These considerations are specifically reviewed in the context of recent policy decisions by the Trump administration, with emphasis on the effects of these decisions on FMGs in medical training and practice.

National Trends and Dynamic Responses in the Canadian Radiation Oncology Workforce From 1990 to 2018.

PURPOSE: To report radiation oncology (RO) workforce and cancer incidence trends in Canada and explore the relationship between the two. METHODS AND MATERIALS: Canadian radiation oncologist, trainee, and cancer incidence data from 1990 to 2018 were collected from the following publicly accessible administrative and health information databases: Canadian Post-MD Education Registry (1990-2018), Canadian Medical Association Physician Data Centre (1994-2018), Canadian Institute for Health Information/Scott's Medical Database (1990-2017), Canadian Cancer Registry (1990-2017), and Statistics Canada (1990-2017). Descriptive statistics were used to summarize the data. RESULTS: The Canadian RO workforce grew from 240 radiation oncologists in 1990 to 567 in 2018, with the largest growth period from 2005 to 2015 adding 207 radiation oncologists. Regional analyses revealed steady or stepwise growth in all Canadian regions, except in Québec, where the number of radiation oncologists decreased from 86 in 1990 to 57 in 2003 before rising to 139 by 2018. Trainee totals were between 54 and 173 per year with 2 periods of growth (1990-1996 and 2001-2008) and regression (1996-2001 and 2008-2018), signifying trainee supply variability. Female proportions of the workforce and trainees, respectively, rose steadily from 18% to 38% and 28% to 50%, while the workforce proportion with non-Canadian medical degrees decreased from 40% to 26%. Radiation oncologists younger than 40 years increased from 70 to 171, whereas those age 60 years and older decreased from 85 in 1990 to 31 in 2002 and then increased to 108 in 2017. Annual cancer incidence rose steadily from 103,780 to 206,290 cases/year. The annual cancer incidence-to-provider ratio fluctuated (364-475:1) and trended lower with time, and proportional cancer incidence-to-provider ratios varied between 0.7:1 and 1.6:1 in Canada's regions before approaching 1:1. CONCLUSIONS: Our study demonstrates the challenges and successes of managing the Canadian radiation oncologist workforce. These data will inform policy makers and other stakeholders to ensure that the profession meets the current and future needs of Canadian cancer patients.

Natives as international medical graduates: A nationwide analysis in Taiwan.

INTRODUCTION: International medical graduates (IMGs) play an important role in many Western countries because of globalization and physician shortages. While the IMGs investigated in most studies were immigrants, few studies have considered the situation in which people native to a given country have studied medicine abroad and then returned to practice in their home country. To illustrate that situation, our study aimed to investigate practicing IMGs in Taiwan by comparing practicing physicians' nationalities to the countries in which the medical schools the IMGs graduated from are located. METHODS: Data were obtained from the annual official statistics released by the Taiwan Medical Association from 1998 to 2017. RESULTS: The number of practicing IMGs in Taiwan increased from 834 (3.1% of 26,991 physicians) in 1998 to 1,733 (3.7% of 46,452) in 2017. Their medical schools were distributed across 37 countries, with graduates of schools in the Philippines (n = 550), Poland (n = 420), and Myanmar (n = 364) accounting for 77.0% of all practicing IMGs in 2017. However, only 29, 0, and 253 physicians were themselves Filipinos, Polish, and Myanmarese, respectively. CONCLUSION: Most of the practicing IMGs in Taiwan are native Taiwanese. The real impact of IMGs in health policy-making and the existing quota system of admissions to medical schools thus deserve further investigations.

Reconfiguring a One-Way Street: A Position Paper on Why and How to Improve Equity in Global Physician Training.

Large numbers of U.S. physicians and medical trainees engage in hands-on clinical global health experiences abroad, where they gain skills working across cultures with limited resources. Increasingly, these experiences are becoming bidirectional, with providers from low- and middle-income countries traveling to experience health care in the United States, yet the same hands-on experiences afforded stateside physicians are rarely available for foreign medical graduates or postgraduate trainees when they arrive. These physicians are typically limited to observership experiences where they cannot interact with patients in most U.S. institutions. In this article, the authors discuss this inequity in global medical education, highlighting the shortcomings of the observership training model and the legal and regulatory barriers prohibiting foreign physicians from engaging in short-term clinical training experiences. They provide concrete recommendations on regulatory modifications that would allow meaningful short-term clinical training experiences for foreign medical graduates, including the creation of a new visa category, the designation of a specific temporary licensure category by state medical boards, and guidance for U.S. host institutions supporting such experiences. By proposing this framework, the authors hope to improve equity in global health partnerships via improved access to meaningful and productive educational experiences, particularly for foreign medical graduates with commitment to using their new knowledge and training upon return to their home countries.

International Medical Graduates in the US Physician Workforce and Graduate Medical Education: Current and Historical Trends.

BACKGROUND: Data show that international medical graduates (IMGs), both US and foreign born, are more likely to enter primary care specialties and practice in underserved areas. Comprehensive assessments of representation trends for IMGs in the US physician workforce are limited. OBJECTIVE: We reported current and historical representation trends for IMGs in the graduate medical education (GME) training pool and US practicing physician workforce. METHODS: We compared representation for the total GME and active practicing physician pools with the 20 largest residency specialties. A 2-sided test was used for comparison, with P < .001 considered significant. To assess significant increases in IMG GME trainee representation for the total pool and each of the specialties from 1990-2015, the slope was estimated using simple linear regression. RESULTS: IMGs showed significantly greater representation among active practicing physicians in 4 specialties: internal medicine (39%), neurology (31%), psychiatry (30%), and pediatrics (25%). IMGs in GME showed significantly greater representation in 5 specialties: pathology (39%), internal medicine (39%), neurology (36%), family medicine (32%), and psychiatry (31%; all P < .001). Over the past quarter century, IMG representation in GME has increased by 0.2% per year in the total GME pool, and 1.1% per year for family medicine, 0.5% for obstetrics and gynecology and general surgery, and 0.3% for internal medicine. CONCLUSIONS: IMGs make up nearly a quarter of the total GME pool and practicing physician workforce, with a disproportionate share, and larger increases over our study period in certain specialties.

The Intersection of National Immigration and Healthcare Policy.

Immigration policy and health care policy remain principal undertakings of the federal government. The two have recently been pursued independently in the judicial and legislative arenas. Unbeknownst to many policymakers, however, national immigration policy and health care policy are linked in ways that, if unattended, could undermine the well-being of a significant portion of the US population, specifically medically underserved rural and urban populations. Using current data from a workforce report of the Association of American Colleges and the published literature, we demonstrate the significant impact that contemporary immigration policy directives may have on the number and distribution of international medical graduates who currently provide-and by the year 2025 will provide-a significant portion of primary health care in the United States, especially in underserved small urban and rural communities.

A comparison of physician emigration from Africa to the United States of America between 2005 and 2015.

BACKGROUND: Migration of health professionals has been a cause for global concern, in particular migration from African countries with a high disease burden and already fragile health systems. An estimated one fifth of African-born physicians are working in high-income countries. Lack of good data makes it difficult to determine what constitutes "African" physicians, as most studies do not distinguish between their country of citizenship and country of training. Thus, the real extent of migration from African countries to the United States (US) remains unclear. This paper quantifies where African migrant physicians come from, where they were educated, and how these trends have changed over time. METHODS: We combined data from the Educational Commission for Foreign Medical Graduates with the 2005 and 2015 American Medical Association Physician Masterfiles. Using a repeated cross-sectional study design, we reviewed the available data, including medical school attended, country of medical school, and citizenship when entering medical school. RESULTS: The outflow of African-educated physicians to the US has increased over the past 10 years, from 10 684 in 2005 to 13 584 in 2015 (27.1% increase). This represents 5.9% of all international medical graduates in the US workforce in 2015. The number of African-educated physicians who graduated from medical schools in sub-Saharan countries was 2014 in 2005 and 8150 in 2015 (304.6% increase). We found four distinct categorizations of African-trained physicians migrating to the US: (1) citizens from an African country who attended medical school in their own country (86.2%, n = 11,697); (2) citizens from an African country who attended medical school in another African country (2.3%, n = 317); (3) US citizens who attended medical school in an African country (4.0%, n = 537); (4) citizens from a country outside Africa, and other than the United States, who attended medical school in an African country (7.5%, n = 1013). Overall, six schools in Africa provided half of all African-educated physicians. CONCLUSIONS: The number of African-educated physicians in the US has increased over the past 10 years. We have distinguished four migration patterns, based on citizenship and country of medical school. The majority of African graduates come to the US from relatively few countries, and from a limited number of medical schools. A proportion are not citizens of the country where they attended medical school, highlighting the internationalization of medical education.

Relocation of Obstetrician-Gynecologists in the United States, 2005-2015.

OBJECTIVE: To examine recent trends in the relocation of obstetrician-gynecologists (ob-gyns) in the United States. METHODS: This longitudinal descriptive study analyzed relocation patterns of ob-gyns between the earliest reference point (2005) and most recently (2015). A physician's county location in a year was compared with his or her location during the previous year. Physician background and county characteristics came from three data resources (Association of American Medical Colleges databases, American Medical Association Physician Masterfile, American Community Survey). A multilevel logistic regression model was used to model factors associated with relocation for the entire period. RESULTS: An average of 2,446 (6.5%) of the 37,385 ob-gyns in practice moved per year. Approximately one third (32.1%) relocated (usually once or twice) during the 10 years with more than half (58.2%) remaining within their state. The odds of relocating were higher if the ob-gyns was young, male, black, or an international medical graduate. Relocations were predominantly to counties that were either urban or with a lower percentage of the population in poverty (less than 21.2%). Although the number of ob-gyns and women 18 years or older increased in most states, the population to ob-gyn ratio increased from 3,155 in 2006 to 3,293 in 2015. Net gains from relocations were most apparent in Florida, California, and Washington, whereas net losses were especially apparent in Michigan, Pennsylvania, Ohio, Illinois, and New York. CONCLUSION: Approximately one in every three ob-gyns in the United States moved at least once in the past 10 years to counties that were predominantly urban or with less poverty. Observing this trend might contribute to a better understanding about the uneven national distribution of ob-gyns.

International Medical Graduates in Radiation Oncology: Historical Trends and Comparison With Other Medical Specialties.

PURPOSE: This is the first National Resident Matching Program analysis evaluating historical patterns of international medical graduates (IMGs) in radiation oncology (RO) and providing comparison with American (MD) medical graduates (AMGs), osteopathic students (DOs), unfilled positions, and other specialties. METHODS AND MATERIALS: National Resident Matching Program data for IMGs were available from 2003 to 2015, with limited data for other specialty matches. The following RO-specific figures were obtained per year: total positions available; total matched positions; number of unfilled positions; and number of IMG, AMG, and DO matches. In addition, the number of IMG matches and total matched positions were obtained for 19 other specialties. Fisher exact tests and χ(2) tests were considered significant at α <.05. RESULTS: From 2010 to 2015, 0.8% of RO matches were IMGs, a decline from 2.4% in 2003 to 2009 (P=.006). Proportions of DO matches during these intervals increased by 40% (from 1.0% to 1.4%), significantly lower than IMGs for 2003 to 2009 (P=.03) but not 2010 to 2015 (P=.26). From 2003 to 2015, the percentage of IMG matches, at 1.5%, was significantly lower than the percentage of unfilled seats, at 3.5% (P<.001). In comparison with other specialties (2003-2015), RO had the fewest IMG matches (1.5%), followed by otolaryngology (1.9%) and orthopedics (2.2%); specialties with the highest IMG proportions were internal medicine (37.1%), family medicine (35.7%), and neurology (31.1%). CONCLUSIONS: Presently, IMGs represent <1% of RO matches, the lowest among major specialties. There are several speculative factors associated with this low proportion. There are significantly more unfilled positions than those filled by IMGs; programs at risk of not matching could weigh the advantages and disadvantages of interviewing IMGs.

Understanding the Interview and Ranking Behaviors of Unmatched International Medical Students and Graduates in the 2013 Main Residency Match.

BACKGROUND: Over the past decade, the number of unfilled positions in the National Resident Matching Program (NRMP) Main Residency Match has declined by one-third, while the number of unmatched applicants has grown by more than 50%, largely due to a rise in the number of international medical school students and graduates (IMGs). Although only half of IMG participants historically have matched to a first-year position, the Match experiences of unmatched IMGs have not been studied. OBJECTIVE: We examined differences in interview and ranking behaviors between matched and unmatched IMGs participating in the 2013 Match and explored strategic errors made by unmatched IMGs when creating rank order lists. METHODS: Rank order lists of IMGs who failed to match were analyzed in conjunction with their United States Medical Licensing Examination (USMLE) Step 1 scores and responses on the 2013 NRMP Applicant Survey. IMGs were categorized as "strong," "solid," "marginal," or "weak" based on the perceived competitiveness of their USMLE Step 1 scores compared to other IMG applicants who matched in the same specialty. We examined ranking preferences and strategies by Match outcome. RESULTS: Most unmatched IMGs were categorized as "marginal" or "weak". However, unmatched IMGs who were non-US citizens presented more competitive USMLE Step 1 scores compared to unmatched IMGs who were US citizens. Unmatched IMGs were more likely than matched IMGs to rank programs at which they did not interview and to rank programs based on their perceived likelihood of matching. CONCLUSIONS: The interview and ranking behaviors of IMGs can have far-reaching consequences on their Match experience and outcomes.