The Price of Becoming a Physician

International students in United States allopathic medical education: a mixed-methods analysis of institutional policies

International medical students (IMS; non-U.S. citizens/permanent residents) greatly enhance the diversity of U.S. medical schools and serve in areas of greatest healthcare needs. Despite 15% of the US population being foreign born, international students represent < 2% of US-MD matriculants. Factors that contribute to this underrepresentation of IMS remain unknown. In this study, we analyzed the accessibility, quality, and inclusivity of publicly available admissions and financial aid policies at all US-MD schools, with the goal of evaluating potential institutional and informational barriers faced by IMS. Institutional webpages and American Association of Medical College (AAMC) databases were searched from May-July 2023 to gather IMS-specific admissions and financial aid information from 153 accredited US-MD schools. Two-tailed t-test or chi-square analysis was used to examine differences. An inductive thematic approach was used to qualitatively categorize institutional webpage friendliness. While 45% (69/153) of U.S.-MD schools reported accepting IMS, only 18% (27/153) admitted students without restrictions (e.g., Canadians only, state/religious preference). Further, 38% (26/69) of the schools that accept IMS did not provide financial aid information, while nearly two-thirds of the remaining schools required proof of personal financial ability with no institutional/federal support. International students also entered schools with a higher average Medical College Admission Test (MCAT) score and Grade Point Average (GPA). In the national AAMC databases, 19 additional programs were listed as accepting IMS although the institutional webpages stated otherwise; the databases also lacked details on specific restrictions posed by the majority of institutions. Of all 153 webpages, only 14% were deemed 'international friendly.' Restrictive admissions and financial aid policies as well as the poor quality and access to information are major barriers that affect IMS. Strategies that aim to overcome these challenges can greatly help advance diversity, equity, and inclusion in medical education.

Integrating multi-national teams: over a decade of lessons learned in Chiapas with Partners in Health-Mexico

In a globalized world where pathology and risk can flow freely across borders, the discipline of global health equity has proposed to meet this challenge with an equal exchange of solutions, and people working toward those solutions. Considering the history of colonialism, ongoing economic exploitation, and gaping inequities across and within countries, these efforts must be taken with care. The Partners In Health program in Chiapas, Mexico was founded in 2011 by a team of leaders from both the United States and Mexico to strengthen the public health and care delivery systems serving impoverished rural populations. Key to the strategy has been to marshal funding, knowledge, and expertise from elite institutions in both the United States and Mexico for the benefit of an area that previously had rarely seen such inputs, but always in close partnership with local leaders and community processes. With now over a decade of experience, several key lessons have emerged in both what was done well and what continues to present ongoing challenges. Top successes include: effective recruitment and retention strategies for attracting talented Mexican clinicians to perform their social service year in previously unappealing rural placements; using effective fund-raising strategies from multinational sources to ensure the health care delivered can be exemplary; and effectively integrating volunteer clinicians from high-income contexts in a way that benefits the local staff, the foreign visitors, and their home institutions. A few chief ongoing challenges remain: how to work with local communities to receive foreign visitors; how to hire, develop, and appropriately pay a diverse workforce that comes with differing expectations for their professional development; and how to embed research in non-extractive ways. Our community case study suggests that multinational global health teams can be successful if they share the goal of achieving mutual benefit through an equity lens, and are able to apply creativity and humility to form deep partnerships.