International medical graduate

An international medical graduate (IMG), earlier known as a foreign medical graduate (FMG), is a physician who has graduated from a medical school outside of the country where he or she intends to practice. The term non-local medical graduate may be similarly used in countries with distinct licensing regions within them.[1][2] Generally, the medical school of graduation is one listed in the International Medical Education Directory (IMED) as accredited by the Foundation for Advancement of International Medical Education and Research or the World Health Organization.

Medical schools around the world vary in education standards, curricula, and evaluation methods. Many countries have their own certification program, equivalent to the ECFMG in the United States. The purpose of ECFMG Certification is to assess the readiness of international medical graduates to enter clinical specialty training programs as resident physicians and fellowship programs in the United States.

License requirements by country

The requirements to obtain a license to practice varies by country and often by state, province, or territory.

Australia
Main article: Overseas trained doctors in Australia

IMGs (or Overseas Trained Doctors) who wish to be licensed in Australia must apply to the Australian Medical Council (AMC) to arrange an appropriate assessment pathway.[3] The standard pathway involves an IMG sitting a series of assessments, including an AMC MCQ Exam and an AMC clinical exam.[4] The AMC MCQ Exam consists of 150 MCQs organized through computer adaptive scoring.

For AMC clinical exam, a candidate is required to pass 12 out of 16 cases: including one compulsory case in both gynecology and pediatrics.

IMGs who have passed the necessary exams and obtained AMC certification can then apply to Australian specialty training positions.[5]

Australia is in the process of establishing a national registration process for all the doctors under theMedical Board of Australia.

In 2010 the Minister for Health and Ageing (Australia) launched an Inquiry process into registration and accreditation processes for international medical graduates which reported in 2012.[6]

Canada

Several organizations have put pressure on the government such as the Association For Access to Health Care Services, and Association of International Physicians and Surgeons of Ontario. Bill 97, Increasing Access to Qualified Health Professionals for Ontarians Act, was passed in 2008, requiring the College of Physicians and Surgeons to provide adequate numbers of doctors by issuing transitional licenses. However, the college has not complied with the law.

In addition to undergoing the regular licensing process as required of all Canadian medical school graduates, IMGs must pass the LMCC Evaluating Examination. IMGs in Canada also have a harder time getting into residency programs compared to Canadian graduates — only ten percent of IMG applicants get a position.[7]

Graduates of United States M.D. programs are not considered IMGs and are thus exempt from the Evaluating Examination; graduates of U.S. osteopathic medical schools are considered IMGs.[8]

United States

Graduates of Canadian M.D. programs are not considered IMGs in the United States.[9]

Indian physicians with a MBBS are qualified to take the USMLE. However, since the 2010s, the process of obtaining a license has become increasingly complicated[10] India has exported more physicians to the United States than any other foreign nation.[11]

Pathway

The main pathway for IMGs who wish to be licensed as physicians in the United States is to complete a U.S. residency hospital program. The general method to apply for residency programs is through the National Resident Matching Program (abbreviated NRMP, also called "the Match"). To participate in the NRMP, an IMG is required to have an ECFMG certification[12] by the "rank order list certification deadline" time (usually in February of the year of the match).[13] To acquire an ECFMG certification, the main requirements are:[14]

In comparison, regular graduates from medical schools in the United States and Canada need to complete USMLE Steps 1 and 2 as well, but can participate in the NRMP while still doing their final year of medical school before acquiring their medical diplomas.[15] In effect, taking regular administrative delays into account, and with residency programs starting around July, there is a gap of at least half a year for IMGs between graduation from medical school and beginning of a residency program.

Those IMGs who have passed the necessary USMLE exams and obtained the ECFMG certification can then apply to U.S. residency positions via the NRMP and ERAS.

USMLE exam scores are considered in the matching process for entering a residency program.[16] One study came to the result that almost half of IMGs were unsuccessful in their first attempts in the pursuit of a U.S. residency position, and three-quarters began a residency after five years.[17] It also indicated that IMGs were considerably older when they first applied for a residency position than are most U.S. medical graduates, with mean age of IMGs when the ECFMG certificate was issued being 32.4 years, with a standard deviation of 5.8 years.[17]

All applicants to residency programs in California need a Postgraduate Training Authorization Letter (PTAL), colloquially called a "California Letter".[18] Obtainment of a PTAL requires graduation from a medical school listed by the Medical Board of California, which is more stringent than the International Medical Education Directory.[19] It also requires having a Social Security number.[20]

Concerning visa requirements, non-U.S.-citizen doctors usually enter via the J1 or the H-1B visa. The J1 requires a 2-year home residence after completion of training in the U.S.[21] The H-1B visa does not have this 2-year home residence requirement, but further requires the USMLE Step 3. And initially, a B-1 visitor visa is required for taking the USMLE Step 2 clinical skills examination and the USMLE Step 3.[22]

Origin by country
Country of medical schoolPercentage of IMGsTotal number (2007)
India19.9%47,581
Philippines8.7%20,861
Mexico5.8%13,929
Pakistan4.8%11,331
Dominican Republic3.3%7,892
Former USSR2.5%6,039
Grenada2.4%5,708
Egypt2.2%5,202
Korea2.1%4,982
Italy2.1%4,978
China2.1%4,834
Iran2.0%4,741
Spain1.9%4,570
Dominica1.9%4,501
Germany1.9%4,457
Syria1.5%3,676
Colombia1.8%3,335
Israel1.4%3,260
United Kingdom1.4%3,245
Montserrat1.3%3,111

Source: 2007 AMA Masterfile[23]

Quality of care

One study examining quality of care by international medical graduates is noted as follows. "One-quarter of practicing physicians in the United States are graduates of international medical schools. The quality of care provided by doctors educated abroad has been the subject of ongoing concern. Our analysis of 244,153 hospitalizations in Pennsylvania found that patients of doctors who graduated from international medical schools and were not U.S. citizens at the time they entered medical school had significantly higher mortality rates than patients cared for by doctors who graduated from U.S. medical schools or who were U.S. citizens and received their degrees abroad. The patient population consisted of those with congestive heart failure or acute myocardial infarction. We found no significant mortality difference when comparing all international medical graduates with all U.S. medical school graduates".[24] Data on older Medicare patients admitted to hospital in the US showed that patients treated by international graduates had lower mortality than patients cared for by US graduates.[25]

References
  1. "Recruiting Non-locally trained Doctors under Limited Registration Scheme in HA" (PDF). Hospital Authority of Hong Kong. Hospital Authority. Retrieved 22 November 2019.
  2. "CUHK medical students seek Shenzhen vows". The Standard. The Standard Newspaper Publishing Ltd. Retrieved 22 November 2019.
  3. "IMG guides: Applying to the Australian Medical Council". Australian Medical Council. 27 February 2012. Retrieved 7 June 2014.
  4. "Assessments & examinations: Standard pathway". Australian Medical Council. 27 February 2012. Archived from the original on 27 June 2014. Retrieved 7 June 2014.
  5. Preliminary information and application form for the AMC Examination Australian Medical Council
  6. "Inquiry into Registration Processes and Support for Overseas Trained Doctors". Parliament of Australia. Retrieved 2 June 2014.
  7. readersdigest.ca - Why Is Canada Shutting Out Doctors?: "In 2003, 625 international graduates competed. Only 67—about ten percent—found a position"
  8. "Evaluating Examination: Apply". Medical Council of Canada. Archived from the original on 2010-04-17. Retrieved 2010-04-16.
  9. "Frequently Asked Questions: 1. What Is ECFMG Certification?". 2010 ECFMG Information Booklet. Educational Commission for Foreign Medical Graduates. Retrieved 2010-04-16. Medical schools outside the United States and Canada vary in their educational standards and curricula. The purpose of ECFMG Certification is to assess whether graduates of these schools are ready to enter U.S. residency and fellowship programs that are accredited by the Accreditation Council for Graduate Medical Education (ACGME).
  10. Rampell, Catherine (2013-08-11). "Path to United States Practice is Long Slog to Foreign Doctors". The New York Times.
  11. "India's Doctors Returning Home".
  12. nrmp.org > Independent Applicants Archived 2011-07-21 at the Wayback Machine Updated 09/08/2010.
  13. nrmp.org > 2012 Main Match Schedule Archived 2011-07-16 at the Wayback Machine Updated 05/19/2011
  14. ecfmg.org > Medical Education Credentials Last update: September 15, 2010
  15. nrmp.org > U.S. Seniors > Registering with the NRMP Archived 2011-07-21 at the Wayback Machine Updated August 2010
  16. Catherine Rampell (August 11, 2018). "Path to United States Practice Is Long Slog to Foreign Doctors". New York Times. Retrieved July 22, 2018.
  17. Participation in U.S. Graduate Medical Education by Graduates of International Medical Schools By Jolly, Paul PhD; Boulet, John PhD; Garrison, Gwen PhD; Signer, Mona M. MPH. Posted: 05/23/2011; Academic Medicine. 2011;86(5):559-564.
  18. Postgraduate Training Authorization Letter (PTAL) or “California Letter”, Educational Commission for Foreign Medical Graduates. Last updated June 4, 2013.
  19. University of California, Los Angeles - PTAL, Updated January 2011
  20. The Medical Board of California - Physicians and Surgeons. Retrieved May 2014.
  21. "Immigration Information for International Medical Graduates". American Medical Association. Retrieved July 22, 2018.
  22. "The 10 Biggest Immigration Mistakes Physicians Make". www.seak.com. 2014-10-14. Retrieved July 22, 2018.
  23. "IMGs by Country of Origin". American Medical Association. Retrieved 7 June 2014.
  24. Norcini 2010, pp. 1467
  25. Tsugawa, Yusuke; Jena, Anupam B.; Orav, E John; Jha, Ashish K. (3 February 2017). "Quality of care delivered by general internists in US hospitals who graduated from foreign versus US medical schools: observational study". BMJ. 356: j273. doi:10.1136/bmj.j273. PMC 5415101. PMID 28153977.
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