"We're IMGs, and we're often seen as human garbage outside of primary care": A qualitative investigation of dynamic status hierarchy construction online by medical trainees.

In the United States health care system, "USMDs," or allopathic US-trained medical graduates, are generally considered higher status than "non-USMDs," or osteopathic and international medical graduates (also abbreviated as IMGs). Two key aspects of this professional hierarchy have yet to be understood: one, how it is socially and culturally reproduced during specific medical training timepoints, such as the US residency placement cycle; and two, how changes within this hierarchy may be occurring among the new generation of medical trainees and professionals. To answer these questions, I qualitatively analyzed comments from a selection of medical student Reddit posts, called "Name and Shame," where users discussed their experiences with discrimination and mistreatment during residency interviews spanning 2018 to 2020. From this analysis, I found that after exposure to and discussion of stories of applicant mistreatment, while some students on the forum reproduced this professional hierarchy, others rejected this inequality, with non-USMD users advocating for themselves and USMD students supporting their lower status peers. These findings highlight that the construction and understanding of this USMD/non-USMD hierarchy may be more dynamic than previously thought, especially among contemporary trainees now entering the medical profession.

Separate but Equal? The Sorting of USMDs and Non-USMDs in Internal Medicine Residency Programs.

BACKGROUND: The US internal medicine workforce relies on international and osteopathic medical graduates to fill gaps in residency. Little is known about the distribution and impact of IMGs, DOs, and USMDs concentrating in different types of IM programs. OBJECTIVE: Determining the extent to which USMDs, DOs, and IMGs concentrate in different types of IM programs and comparing Board pass rates by program concentration. DESIGN, SETTINGS, AND PARTICIPANTS: This survey study used data from the AMA's FREIDA database for 476 non-military IM programs in 2017-2018, and 2016-2018 ABIM exam pass rates for 388 accredited programs. MEASUREMENTS: Outcomes were (1) program concentration based on percentage of residents who were USMDs, IMGs, and DOs in 2017-2018 and (2) 2016-2018 program ABIM pass rates as proxies for program quality. Key independent variables were hospital type (community-based, community-based university-affiliated, or university-based) when program concentration was the outcome, and program concentration when Board pass rates were the outcome. RESULTS: Twenty-five percent of programs were "USMD-dominated," 17% were "DO-dominated," 42% were "IMG dominated," and 16% were "integrated." The chances that a university hospital was USMD-dominated were 32 percentage points higher than that for a community hospital (AME = 0.32, baseline probability = 0.11, 95% CI, 0.17-0.46, P < .001). USMD-dominated programs also had significantly higher pass rates by 4.0 percentage points (AME = 0.04, baseline proportion = 0.90, 95% CI, 0.02-0.06, P < .001) than integrated programs, while DO-dominated programs had significantly lower pass rates (AME = - 0.1, baseline proportion = 0.90, 95% CI, - 0.15 to - 0.04, P < .001). CONCLUSION: USMDs and non-USMDs systematically cluster in certain types of residency programs and their training may not be equal, as measured by board pass rates.