Evaluating the quality of care provided by graduates of international medical schools

World Psychiatric Association-Asian Journal of Psychiatry Commission on the Mental Health and Wellbeing of International Medical Graduates

Historically, doctors have migrated for a range of personal, educational, economic, and political reasons. Likewise, medical students from many countries have moved abroad to complete their training and education and may or may not return to their country of origin. Within this context, globalisation has had a major impact on medical education and healthcare workforces, contributing to recent migration trends. Globalisation is a complex phenomenon with positive and negative outcomes. For example, lower-income countries are regularly losing doctors to higher-income areas, thereby exacerbating strains on existing services. Across various national healthcare settings, migrating International Medical Graduates (IMGs) can face socioenvironmental and psychosocial pressures, which can lead to lower mental wellbeing and undermine their contributions to clinical care. Rates of stress and burnout are generally increasing for doctors and medical students. For IMGs, stressors related to migration, acculturation, and adjustment are not dissimilar to other migrants but may carry with them specific nuances. Accordingly, this Commission will explore the history of IMG trends and the challenges faced by IMGs, proposing recommendations and solutions to support their mental health and wellbeing.

Multicultural personality profiles and nursing student attitudes towards refugee healthcare workers: A national, multi-institutional cross-sectional study

BACKGROUND

Multicultural organizations in the era of globalization require intercultural leadership skills. Healthcare, as a sector serving diverse populations, necessitates culturally sensitive staff. Intercultural nurse education should start in undergraduate education. A tailored approach is needed, especially in the context of Poland's refugee crisis.

OBJECTIVE

To investigate how a multicultural personality profile and specific intercultural perspectives affect the attitudes of nursing students towards Ukrainian refugee background healthcare professionals.

DESIGN

A nationwide cross-sectional multicentre online survey study was conducted. The questionnaire was distributed with the aid of the Lime Survey web platform.

METHODS

The study utilized a Polish version of the Multicultural Personality Questionnaire. The questionnaire also included demographics and questions assessing intercultural competence and attitudes towards refugee medical professionals. K-Means Cluster Analysis was used to classify different patterns of multicultural personality. P-value <0.05 was deemed to be statistically significant.

PARTICIPANTS

The study sample consisted of 1325 undergraduate nursing students from 39 nursing schools in Poland: 54.0% in first year, 28.7% in second year, and 17.3% in third year. Most respondents were female (N = 1229, 90%).

RESULTS

Using cluster analysis respondents were categorized into four groups based on their level of three analyzed multicultural personality traits: cultural empathy, social initiative, and open-mindedness (high, low, average or mixed level). Statistical analysis demonstrated that personality profiles significantly affected nursing students' attitudes towards refugee health professionals (p = 0.003). Additionally, students' willingness to engage in intercultural communication classes and their belief in the learnability of intercultural competence also impacted their attitudes (p < 0.001 for both). Further analysis revealed correlations between personality profiles, belief in competency acquisition, and willingness to enhance competencies.

CONCLUSION

The design of intercultural competence education for undergraduate nursing students should be preceded by a mapping of the students' personality profile and a needs analysis in this regard, which may contribute to long-term effectiveness of such initiatives.

Normalized "medical inferiority bias" and cultural racism against international medical graduate physicians in academic medicine

Socio-historical barriers remain a concern in Academic Medicine. Regrettably, despite the modern cultural era defined by increased recognition and response to such issues, widespread covert barriers and misperceptions continue to limit the advancement of many, in particular, international medical graduate physicians (IMGs) who represent a significant proportion of the US physician workforce. Adversity is experienced in the form of cultural racism, affinity bias, and underrepresentation in distinct specialties as well as in leadership roles. Often, these unnecessary hardships exacerbate pre-existing discrimination in Academic Medicine, further marginalizing IMGs. In this article, we discuss the prevalence of "medical inferiority bias" and the resulting impact on US healthcare, specifying considerations to be made from a policy perspective.

Bibliometric Analysis of International Medical Graduates and Professorship Promotion in Neurosurgery

BACKGROUND

International medical graduates (IMGs) comprise ∼25% of physicians in the United States. Differences in promotion rates from assistant to associate to full professorship based on medical school location have been understudied. We aim to stratify odds of professional advancement by 3 categories: IMG with U.S. residency, IMG with international residency, and U.S. medical with U.S. residency training.

METHODS

We created and queried a database after exclusions of 1334 neurosurgeons including multiple demographic factors: academic productivity and promotion rates. Stratified logistic regression modeled odds of promotion including the variables: decades out of training, Scopus h-index, gender, and training location. Odds ratios (ORs) and 95% confidence intervals (CIs) for each variable were calculated.

RESULTS

Significant predictors of increased associate versus assistant professorship included decades out of training (OR = 2.519 [95% CI: 2.07-3.093], P < 0.0001) and Scopus h-index (OR = 1.085 [95% CI: 1.064-1.108], P < 0.0001) while international medical school with U.S. residency (OR = 0.471 [95% CI: 0.231-0.914], P = 0.0352) was associated with decreased promotion. Significant predictors of associate versus full professorship were decades out of training (OR = 2.781 [95% CI: 2.268-3.444], P < 0.0001) and Scopus h-index (OR = 1.064 [95% CI: 1.049-1.080], P < 0.0001). Attending medical school or residency internationally was not associated with odds of full professorship.

CONCLUSIONS

Time out of residency and Scopus h-index were associated with higher academic rank regardless of career level. Attending medical school internationally with U.S. residency was associated with lower odds of associate professorship promotion over 10 years. There was no relationship between IMG and full professorship promotion. IMGs who attended residency internationally did not have lower promotion rates. These findings suggest it may be harder for IMGs to earn promotion from assistant to associate professor in neurosurgery.

A Primer on General Surgery Applicants Who Have Graduated From Indian Medical Schools

Background: Graduates of Indian medical schools account for the greatest proportion of non-US born international medical graduates applying to general surgery residency programs.Purpose: Provide information to facilitate fair and holistic review of applicants from Indian medical schools.Research Design: Comprehensive review of the Indian medical education system, including history, regulatory agencies, medical school admission, curriculum, cultural differences, immigration issues, and outcomes after residency.Results: The Indian medical education system is one of the world's oldest. The number of medical schools and graduates continues to increase. Medical school admission criteria are variable. Recent regulatory changes have improved the quality of applicants entering the US. Emphasis on academic performance over volunteerism as well as communication styles differ from US graduates. The success of graduates during and after residency is well documented.Conclusions: Understanding the differences in the US and Indian medical education systems will provide a basis for the fair evaluation of applicants.

Altruism or nationalism? Exploring global discourses of medical school regulation

BACKGROUND

Although medical school regulation is ubiquitous, the extent to which it should be based on global principles is unclear. In 2010, the Educational Commission for Foreign Medical Graduates (ECFMG) announced that from 2023, overseas doctors would only be eligible for certification to practise in the United States if they had graduated from a medical school that was accredited by a 'recognised' agency. This policy empowered the World Federation for Medical Education (WFME) to create a recognition programme for regulatory agencies around the world, despite a lack of empirical evidence to support medical school regulation.

METHODS

This study employs critical discourse analysis, drawing on the theoretical perspectives of Michel Foucault and Edward Said, to identify discourses that enabled this 'globalising' policy decision to take place. The dataset includes a series of 250 documents gathered around three key events: the Edinburgh declaration by WFME in 1988, the first set of global standards for medical schools by WFME in 2003 and the ECFMG ruling about medical school accreditation in 2010.

FINDINGS

Two discourses, endorsement and modernisation, were dominant throughout this entire period and framed the move to globalise medical school regulation in terms of altruism and improving medical education worldwide. A discourse of resistance was present in the earlier period of this study but faded away as WFME aligned itself with ECFMG after 2010. Two further discourses, protection and control, emerged in the later period of this study and framed the ECFMG ruling in terms of nationalism and protecting American interests.

DISCUSSION

This study proposes a new conceptualisation of the relationship between ECFMG and WFME in light of the apparently contradictory policy motivations of altruism and nationalism. It goes on to consider the implications of this association for the legitimacy of WFME as an organisation that represents all of the world's medical schools.

"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.

Diversity in dermatology: International medical graduates and their role in the diversity of a specialty

A diverse medical workforce improves patient care. Dermatology is the second-least diverse medical specialty in the United States, and many recent publications have discussed the different reasons and possible solutions to improve this disparity. A quarter of physicians in the United States are international medical graduates, which directly affects the cultural diversity in health care. Dermatology has the lowest percentage of international medical graduates in its active physician workforce. Among other measures, the inclusion of more international medical graduates in residency programs can help improve the diversity in this specialty and alleviate any disparities in dermatological care delivery in underserved communities.

Choices of Specialties and Training Sites among Taiwanese Physicians Graduating from Polish Medical Schools

Taiwanese students who graduated from Polish medical schools (P-IMGs) accounted for the second-largest group of international medical graduates in Taiwan. In 2009, domestic medical students in Taiwan staged mass demonstrations against P-IMG’s exemption from the qualifying test before the licensing exam. Although medical circles in Taiwan might still hold prejudices against P-IMGs, little is known about their career development. This study will analyze P-IMGs’ choices of specialties and training sites from 2000 to 2020 using data from the membership section of the Taiwan Medical Journal, the monthly official publication of the Taiwan Medical Association. Of 372 P-IMGs, 34.2% chose internal medicine and 17.1% surgery. Although academic medical centers offered 76% of all available trainee positions in a year, only 49.3% of P-IMGs received training there. By contrast, 20.9% of P-IMGs were trained at nonmetropolitan hospitals that altogether accounted for only 5.8% of trainee positions. In conclusion, P-IMGs had their residency training at less favorable specialties and sites. Their long-term career development deserves further study.

International Medical Graduate Resident Wellness: Examining Qualitative Data From J-1 Visa Physician Recipients

PURPOSE

International medical graduates (IMGs), approximately 25% of the U.S. physician workforce, have unique needs as they enter residency programs. This study identified wellness barriers and challenges that IMGs encounter as they transition to the United States.

METHOD

The authors analyzed results from 3 open-ended questions in a 21-item survey. This survey was administered in December 2019 to 11,504 IMG resident physicians sponsored by the Educational Commission for Foreign Medical Graduates' J-1 visa program. These questions asked respondents to describe challenges to their wellness, how they maintain wellness, and resources that would have aided their transition. Data were analyzed using a mixed-methods approach, including both qualitative descriptions and category frequencies.

RESULTS

Of the surveys administered, 7,817 responses (68% response rate) were received. Respondents identified challenges navigating cultural differences (1,314, 17%), health care system (1,108, 14%), distance from family and friends (890, 11%), bureaucratic barriers (724, 9%), and language/communication and finances (575, 7%; 565, 7%, respectively). They also specified that friendships/relationships (2,800, 36%) followed by exercise (2,318, 30%), family (1,822, 23%), socialization (1,001, 13%), and healthy eating (775, 10%) were factors important to their wellness. Respondents requested more information about socialization (741, 9%), bureaucratic support (456, 6%), IMG support networks (427, 5%), financial support (404, 5%), and greater online resources (240, 3%).

CONCLUSIONS

IMGs have needs and concerns specific to their demographic group. Participants' responses suggested that they wanted additional support in the workplace and their personal lives. Answers also indicated that IMGs experienced a unique set of stressors such as fluctuating immigration laws that U.S. medical graduates do not face. Finally, this study supports a body of research that connects social and physical wellness. By identifying and describing these challenges, the authors seek to inform the development of specific programs and resources to improve IMG resident wellness.

The American Board of Radiology's Alternate Pathway for Diagnostic Radiology: What the Programs and the Applicants Need to Know

The American Board of Radiology (ABR) developed the international medical graduate alternate pathway to give foreign trained radiologists an alternate route to independent radiology practice without having to undergo radiology residency in the United States. After 4 years of fellowship/faculty experience in the same training institution, the foreign trained radiologist becomes eligible to sit for the radiology board examinations conducted by the ABR. As this pathway is not offered at every radiology training program, many training institutions are unfamiliar with the fundamentals of this pathway. At the same time, both the training institutions and the applying foreign-trained physicians face a plethora of confusing choices on the state and federal level. In this paper, we review the main factors which both the international medical graduate radiologists and training programs must consider before embarking on the diagnostic radiology ABR Alternate Pathway, namely, eligibility, visa options, state medical licensure requirements, their costs and implications for future employment opportunities.

Disaggregating inequalities in the career outcomes of international medical graduates in the United States

Although research finds that international medical graduates (IMGs) fill gaps in US health care left by US medical graduates (USMGs), the extent to which IMGs' career outcomes are stratified along the lines of their country of medical education remains understudied. Using data from the 2019 American Medical Association Physician Masterfile (n = 19,985), I find IMGs from developed countries chart less marginalised paths in their US careers relative to IMGs from developing countries; they are more likely to practise in more competitive and popular medical specialities; to attend prestigious residency programmes; and to practise in less disadvantaged counties that employ more USMGs relative to IMGs. These findings suggest IMGs experience divergent outcomes in the United States based on their place of medical education, with IMGs from developing countries experiencing more constraints in their careers relative to IMGs from developed countries. This understudied axis of stratification in medicine has important implications for our understanding of how nativism and racism may intersect to generate inequalities in the medical profession and in US health care more broadly.

Foreign-Trained Physicians in the United States: A Descriptive Profile

More than a quarter of physicians in the United States are international medical graduates (IMGs). This statistic, although large, does not fully capture the importance of IMGs in certain specialties and locations. We provide a comprehensive profile of IMGs documenting where and in what specialties they work and how these distributions have changed over time. Estimates show that IMGs disproportionately work in densely populated, low-income communities with sicker residents and low physician density. IMGs are overrepresented in primary care and the lowest paying specialties, and their concentration in these specialties is growing. Calculations show that U.S. medical graduates exit the workforce at 2.5 times the exit rate of IMGs suggesting that in the near future IMGs will likely provide care for an increasingly larger share of Americans.

Comparison of Patient Outcomes of Surgeons Who Are US Versus International Medical Graduates

OBJECTIVE

The aim of this study was to compare patient outcomes between International Medical Graduate (IMG) versus US medical graduate (USMG) surgeons.

SUMMARY BACKGROUND DATA

One in 7 surgeons practicing in the US graduated from a foreign medical school. However, it remains unknown whether patient outcomes differ between IMG versus USMG surgeons.

METHODS

Using 20% random sample of Medicare fee-for-service beneficiaries aged 65 to 99 years who underwent 1 of 13 common nonelective surgical procedures (as a "natural experiment" as surgeons are less likely to select patients in this context) in 2011 to 2014 (638,973 patients treated by 37,221 surgeons for the mortality analysis), we compared operative mortality, complications, and length of stay (LOS) between IMG and USMG surgeons, adjusting for patient and surgeon characteristics and hospital-specific fixed effects (effectively comparing IMG and USMG surgeons within the same hospital). We also conducted stratified analyses by patients' severity of illness and procedure type.

RESULTS

We found no evidence that patient outcomes differ between IMG and USMG surgeons for operative mortality [adjusted mortality, 7.3% for IMGs vs 7.3% for USMGs; adjusted odds ratio (aOR), 1.01; 95% confidence interval (CI), 0.96-1.05; P = 0.79], complication rate (adjusted complication rate, 0.6% vs 0.6%; aOR, 0.95; 95% CI, 0.85-1.06; P = 0.43), and LOS (adjusted LOS, 6.6 days vs 6.6 days; adjusted difference, +0.02 days; 95% CI, -0.05 to +0.08; P = 0.54). We also found no difference when we stratified by severity of illness and procedures.

CONCLUSION

Using national data of Medicare beneficiaries who underwent common surgical procedures, we found no evidence that outcomes differ between IMG and USMG surgeons.

The case for refugee physicians: Forced migration of International Medical Graduates in the 21st century

In this paper we propose a new category of International Medical Graduates (IMGs) who are forced to leave their home countries: "refugee physicians." In US social science scholarship, IMGs are divided into US citizen IMG (USIMG) and non-US citizen IMG (non-USIMG). For purposes of US medical licensure qualifications and recordkeeping, US- and non-USIMGs are lumped together. These categorizations are too blunt to demonstrate important differences among non-USIMGs. The category of "refugee physicians" distinguishes non-USIMGs who are forced to flee their homelands from other IMGs. We define and develop this category based on qualitative in-depth interviews conducted in 2019 with 28 non-USIMGs who fled to the US within the past 15 years. Using narrative analysis, we constructed "flight biographies," storied chronological events and experiences, for each physician. The flight biographies highlight the medical and political contexts in which they were forced to flee and are situated in the US. Two representative cases demonstrate how and why lumping refugee physicians together with other IMGs obscures the constraints and challenges that set them apart from the other IMG categories. First, the term refugee physician focuses attention on how physicians are located among forcibly displaced people worldwide, including their distinct relationships to their home countries, transit countries in which some of them seek sanctuary, and the US, where some requested asylum and others have been resettled. Second, because refugee is an umbrella term that blends categories of law, policy, social science, and everyday usage it encompasses a wide variety of lived experiences along a continuum of compulsion to leave. Finally, refugee physician illuminates the group's distinct relationship to medical licensure and brings into focus structural barriers that impede their goal of gaining a US medical license.

Prevalence and Characteristics of Non-US-Born and US-Born Health Care Professionals, 2010-2018

Importance

Immigration to the US results in greater racial/ethnic diversity. However, the contribution of immigration to the diversity of the US health care professional (HCP) work force and its contribution to health care are poorly documented.

Objective

To examine the sociodemographic characteristics and workforce outcomes of non-US-born and US-born HCPs.

Design, Setting, and Participants

This cross-sectional study used national US Census Bureau data on US-born and non-US-born HCPs from the American Community Survey between 2010 and 2018. Demographic characteristics and occupational data for physicians, advanced practice registered nurses, physician assistants, registered nurses, licensed practical nurses or licensed vocational nurses, and other HCPs were included for analysis. Data were analyzed between December 2020 and February 2021.

Exposures

Nativity status, defined as US-born HCP vs non-US-born HCP (further stratified by <10 years or ≥10 years of stay in the US).

Main Outcomes and Measures

Annual hours worked, proportion of work done at night, residence in medically underserved areas and populations, and work in skilled nursing/home health settings. Inverse probability weighting of 3 nativity status groups was carried out using logistic regression. F test statistics were used to test across-group differences. Data were weighted using American Community Survey sampling weights.

Results

Of a total of 657 455 HCPs analyzed (497 180 [75.5%] women; mean [SD] age, 43.7 [13.0] years; 518 317 [75.6%] White, 54 233 [10.8%] Black, and 60 680 [9.6%] Asian), non-US-born HCPs (105 331 in total) represented 17.3% (95% CI, 17.2%-17.4%) of HCPs between 2010 and 2018. They were older (mean [SD] age, 44.7 [11.6] years) and had more education (75 227 [70.1%] HCPs completed college) compared with US-born HCPs (mean [SD] age, 43.4 [13.3] years; 304 601 [55.2%] completed college). Nearly half of non-US-born HCPs (47 735 [43.0%]) were Asian. In major metropolitan areas, non-US-born HCPs represented 40% or more of all HCPs. Compared with US-born HCPs, non-US-born HCPs with less than 10 years and 10 or more years of stay worked 32.3 hours (95% CI, 19.2 to 45.4 hours) and 71.6 hours (95% CI, 65.1 to 78.2 hours) more per year, respectively. Compared with US-born HCPs, non-US-born HCPs were more likely to reside in areas with shortages of health care professionals (estimated percentage: <10 years, 75.3%; ≥10 years, 62.8% vs US-born, 8.3%) and work in home health settings (estimated percentage: <10 years, 17.5%; ≥10 years, 13.1% vs US-born, 12.8%).

Conclusions and Relevance

The contributions of non-US-born HCPs to US health care are substantial and vary by profession. Greater efforts should be made to streamline their immigration process and to harmonize training and licensure requirements.

Regulating high-skilled immigration: The market for medical residents

The effect of high-skill immigration remains central to many US industries and policy debates. Beginning in 2009, the federal government heightened enforcement of existing laws and increased employer fees for the cost of obtaining certain common immigration visas. The change can be viewed as a de facto tax on immigrant labor. I estimate the extent to which high-skill non-citizen workers, in the form of international medical school graduates seeking residency training in US teaching hospitals, are displaced by US citizens who received their medical school training abroad. Changes in immigration policy can have important effects in this labor market with implications for the larger health care system. I find that demand for medical residents among teaching hospitals based on immigration status is highly responsive to increased regulatory cost.

International Medical Graduates: Promoting Equity and Belonging

International medical school graduates (IMGs) play a vital role in the health care system of the United States. They constitute roughly one-quarter of the physician workforce, comprising a significant proportion of the primary care providers in high-need rural and urban areas, where they provide equal and, in some instances, better care than U.S. graduates. Nonetheless, they face a series of hurdles in entering U.S. residency programs and throughout their training experiences.IMGs must expend significant resources to obtain Education Commission for Foreign Medical Graduates certification, which includes Steps 1, 2 Clinical Knowledge and 2 Clinical Skills of the United States Medical Licensing Examination. They encounter the uncertainty of matching and, if successful, obtaining a visa to enter the United States. Once here, they need to adapt to the complexities of the health care system and familiarize themselves with the cultural nuances, professional behaviors, and communication skills of another country. They encounter biases and microaggressions and lack support groups and mentors. Those who choose an academic career are less likely to obtain leadership positions.This Perspective provides an overview of these challenges and highlights opportunities for change at local and national levels. Specifically, it identifies strategies that would assist IMGs before entry, at entry, during training, at the transition to practice, and in practice. The current COVID-19 pandemic highlights the shortage of physicians in the United States and illustrates the importance of ensuring that IMGs, who are essential health care workers, feel welcome, valued, and recognized for their contributions.

Differential attainment in the MRCPsych according to ethnicity and place of qualification between 2013 and 2018: a UK cohort study

PURPOSE OF THE STUDY

To explore if differential pass rates exist in the clinical component of the UK postgraduate clinical psychiatry exam, the Clinical Assessment of Skills and Competencies (CASC), according to ethnicity and place of qualification (UK vs EEA vs overseas graduates).

STUDY DESIGN

Observational study using data from the UK Medical Education Database for 2140 doctors sitting the CASC for the first time between 2013 and 2018.

RESULTS

After controlling for age, sex, time of sitting and performance in the written components of the MRCPsych, differences in CASC pass rates persisted between UK graduates self-identifying as Black and Minority Ethnicity (BME) and non-BME (OR for passing 0.36, 95% CI 0.23 to 0.56, p<0.001). Both EEA (OR 0.25, 0.15 to 0.40, p<0.001) and overseas graduates (OR 0.07, 0.05 to 0.11, p<0.001) were less likely to pass the CASC at first attempt, even after controlling for the influence of educational and background variables. These groups, on average, had lower scores on written exams with substantial content relating to procedural skills (eg, critical appraisal) rather than pure recall of factual knowledge.

CONCLUSIONS

Substantial differences exist in clinical examination performance between UK BME and non-BME candidates, as well as between UK and non-UK graduates. These differences are not explained by differing levels of clinical knowledge. In the interests of equality, this situation requires further investigation and remediation. Future research should focus on understanding how potential bias may be acting within different stages of recruitment, training and assessment within psychiatry.

Addressing the rheumatology workforce shortage: A multifaceted approach

A significant challenge facing the field of rheumatology is the projected gap between the growing demand for rheumatologists and the available workforce. In order to improve access to care, augmenting the rheumatology workforce is required. Herein we discuss potential solutions to the anticipated workforce shortage, including 1) expanding the training of rheumatology physicians; 2) increasing nurse practitioner, physician assistant and pharmacist utilization in rheumatology practice; 3) growing the use of telemedicine; and 4) reducing burnout in order to retain practicing rheumatologists. Building on the existing literature in these areas, we propose a multifaceted approach to addressing the rheumatology workforce shortage.

We Must Graduate Physicians, Not Doctors

Today, medical schools graduate doctors, not physicians. Thousands of doctors who are U.S. citizens and graduates of U.S. and international medical schools will never become physicians because they do not obtain a residency position. Doctors need at least one year of residency to become a licensed physician. However, 4,099 applicants in 2018 and 4,170 in 2019 failed to get a position through the National Resident Matching Program Main Match; about 1,000 students get positions after the Main Match each year. The personal and societal cost is enormous: each year, approximately 3,000 nonphysician doctors cannot use 12,000 education years and three-quarters of a billion dollars they invested in medical education and cannot mitigate the shortfall of 112,000 physicians expected in 2030.To ameliorate this problem, medical schools could guarantee one year of residency. This is affordable: despite federally funded slots being capped, residency positions have increased for 17 consecutive years (20,602 in 2002 to 32,194 in 2019) because residents are cost-effective additions to the workforce. Alternatively, a 3-year curriculum plus required fourth-year primary care residency is another option. The salary during the residency year could equal other first-year residents', or there could be a token amount for this "internship." Both models decrease the cost of medical education; the second financially unburdens the hospital.Since the Flexner Report (when there was no formal postgraduate training), the end point of medical education has moved from readiness for independent medical practice (physician) to readiness for postgraduate training (doctor). To benefit individuals and society, medical education must take steps to ensure that all graduates are physicians, not just doctors.

Association of Adenoma and Proximal Sessile Serrated Polyp Detection Rates With Endoscopist Characteristics

Importance

Research demonstrates adenoma detection rate (ADR) and proximal sessile serrated polyp detection rate (pSSPDR) are associated with endoscopist characteristics including sex, specialty, and years in practice. However, many studies have not adjusted for other risk factors associated with colonic neoplasia.

Objective

To assess the association between endoscopist characteristics and polyp detection after adjusting the factors included in previous studies as well as other factors.

Design, Setting, and Participants

This cohort study was conducted in the Cleveland Clinic health system with data from individuals undergoing screening colonoscopies between January 2015 and June 2017. The study analyzed data using methods from previous studies that have demonstrated significant associations between endoscopist characteristics and ADR or pSSPDR. Multilevel mixed-effects logistic regression was performed to examine 7 endoscopist characteristics associated with ADRs and pSSPDRs after controlling for patient demographic, clinical, and colonoscopy-associated factors.

Exposures

Seven characteristics of endoscopists performing colonoscopy.

Main Outcomes and Measures

The ADR and pSSPDR, with a hypothesis created after data collection began.

Results

A total of 16 089 colonoscopies were performed in 16 089 patients by 56 clinicians. Of these, 8339 patients were male (51.8%), and the median (range) age of the cohort was 59 (52-66) years. Analyzing the data by the methods used in 4 previous studies yielded an association between endoscopist and polyp detection; surgeons (OR, 0.49 [95% CI, 0.28-0.83]) and nongastroenterologists (OR, 0.50 [95% CI 0.29-0.85]) had reduced odds of pSSPDR, which was similar to results in previous studies. In a multilevel mixed-effects logistic regression analysis, ADR was not significantly associated with any endoscopist characteristic, and pSSPDR was only associated with years in practice (odds ratio, 0.86 [95% CI, 0.83-0.89] per increment of 10 years; P < .001) and number of annual colonoscopies performed (odds ratio, 1.05 [95% CI, 1.01-1.09] per 50 colonoscopies/year; P = .02).

Conclusions and Relevance

The differences in ADRs that were associated with 7 of 7 endoscopist characteristics and differences in pSSPDRs that were associated with 5 of 7 endoscopist characteristics in previous studies may have been associated with residual confounding, because they were not replicated in this analysis. Therefore, these characteristics should not influence the choice of endoscopist for colorectal cancer screening. However, clinicians further from their training and those with lower colonoscopy volumes have lower adjusted pSSPDRs and may need additional training to help increase pSSPDRs.

Identification of Factors Associated with Hematology-Oncology Fellow Academic Success and Career Choice

Factors affecting hematology-oncology trainees' academic success and career choices have not been well characterized. We performed a retrospective study of 57 hematology-oncology fellows trained at Mayo Clinic between 2008 and 2017 in an attempt to identify factors associated with success during fellowship and with career choice (academic versus private). Sex, age, residency quality, and letters of recommendation indicating a "top" applicant were not associated with hematology or oncology in-training examination (ITE) scores, research productivity (abstracts/publications during fellowship), or career choice (academic versus private). Fellows with higher United States Medical Licensing Examination (USMLE) scores were more likely to perform well on ITE, but examination scores did not predict academic productivity or academic versus private career choice. More academically productive fellows were more likely to choose academic careers. Both ITE scores and productivity were associated with receipt of national and/or institutional awards. Finally, fellows who were non-US citizens and/or international medical graduates (IMG) had higher academic productivity both pre-fellowship and during fellowship and as per the observations above were more likely to choose academic careers. In conclusion, predictors of superior knowledge differ from predictors of academic productivity/career choice, and it is important to take multiple factors into account when selecting candidates most likely to succeed during fellowship.

American Cleft-Palate Craniofacial Association Annual Meeting: International Medical Graduate's Perspective as a First-Time Attendee

In the United States, plastic surgery continues to be one of the most competitive fields to match into for medical graduates. However, the process is even more difficult for international medical graduates (IMGs) mostly due to their unknown academic backgrounds and unfamiliarity with US health-care system. While many IMGs pursue of research to publish articles in peer-reviewed journals and obtain letters of recommendations as a means to prove one's potential, networking with well-known plastic surgeons in US plastic surgery programs via national meetings is of utmost importance. These conferences provide the perfect opportunity to learn about the multidisciplinary US health-care system, expand one's network of mentors and colleagues, and demonstrate one's research experience. This article describes my experience as a first-time attendee in the American Cleft-Palate Craniofacial Association 76th Annual Meeting, with the aim to encourage other IMGs interested in applying to plastic surgery residency programs to actively pursue and attend national plastic surgery society meetings.

Examining the Educational Commission for Foreign Medical Graduates Announcement Requiring Medical School Accreditation Beginning in 2023

In 2010, the Educational Commission for Foreign Medical Graduates (ECFMG, Philadelphia, Pennsylvania) announced that, beginning in 2023, graduation from a formally accredited medical school would be necessary for an international medical graduate (IMG) to be eligible for ECFMG certification. The announcement is notable because ECFMG certification is required for graduate medical training and practice in the United States. Graduating from a school accredited by an agency formally recognized by the World Federation for Medical Education (WFME), which has been formally evaluating and recognizing accrediting agencies since 2012, would fulfill the new ECFMG requirement. In 2015, ECFMG applicants came from 1,141 medical schools located in 139 countries or territories. As of December 2018, the WFME had formally recognized 14 accrediting agencies, which would cover only approximately a third of these recent ECFMG-certified IMGs. In this Perspective, the author compares the context of the ECFMG announcement to the beginning of accreditation in the United States so as to provide insight into the challenges the WFME faces as it seeks to evaluate and recognize what could ultimately be over 100 more accrediting authorities. The author then explores the possible effects of the requirement-specifically, its potential to restrict the ECFMG applicant pool-on the quantity and quality of the U.S. physician workforce. The author ends the Perspective by considering the implications of three broad policy options that the ECFMG could consider starting in 2023: implementation as announced, maintenance of the status quo, or a policy modified from the original announcement.

A Further Examination of Previous and Future Policy Opportunities of the Educational Commission for Foreign Medical Graduates

The Educational Commission for Foreign Medical Graduates (ECFMG) has a distinguished history of providing high-quality, innovative products and services to international medical graduates (IMGs) seeking to study and practice medicine in the United States. In 2010, the ECFMG board introduced a policy stating that, starting in 2023, all IMGs applying to the ECFMG for credentialing must have graduated from a medical school that has been accredited by an internationally recognized accrediting body akin to the Liaison Committee on Medical Education in the United States or the World Federation for Medical Education. In this issue of Academic Medicine, Tackett reviews the reasons for the policy and its adoption worldwide. After eight years, the number of schools meeting the new standard is modest. He is concerned about the negative effect a continuing low rate of adoption will have on U.S. postgraduate medical education programs and workforce supply. The author of this Invited Commentary offers three perspectives: an overview of the ECFMG's successes, alternative measurement tools to ensure the quality of IMGs entering the United States, and frameworks by which an organization like the ECFMG can refine its policy positions and processes for the future. Academia can expect the ECFMG, given its history of successful collaboration and public accountability, to continue using best practices and to adjust policies according to evidence. As a publicly accountable authority, the ECFMG should debrief key stakeholders on current policies, track IMG practice patterns, and share the resulting data with stakeholders to inform their IMG-related planning decisions.

Primary care performance of alternatively licenced physicians in Ontario, Canada: a cross-sectional study using administrative data

OBJECTIVES

Medical Regulatory Authorities (MRAs) provide licences to physicians and monitor those physicians once in practice to support their continued competence. In response to physician shortages, many Canadian MRAs developed alternative licensure routes to allow physicians who do not meet traditional licensure criteria to obtain licences to practice. Many physicians have gained licensure through alternative routes, but the performance of these physicians in practice has not been previously examined. This study compared the performance of traditionally and alternatively licenced physicians in Ontario using quality indicators of primary care. The purpose of this study was to examine the practice performance of alternatively licenced physicians and provide evaluative evidence for alternative licensure policies.

DESIGN

A cross-sectional retrospective examination of Ontario health administrative data was conducted using Poisson regression analyses to compare the performance of traditionally and alternatively licenced physicians.

SETTING

Primary care in Ontario, Canada.

PARTICIPANTS

All family physicians who were licenced in Ontario between 2000 and 2012 and who had complete medical billing data in 2014 were included (n=11 419).

OUTCOME MEASURES

Primary care quality indicators were calculated for chronic disease management, preventive paediatric care, cancer screening and hospital readmission rates using Ontario health administrative data.

RESULTS

Alternatively licenced physicians performed similarly to traditionally licenced physicians in many primary care performance measures. Minimal differences were seen across groups in indicators of diabetic care, congestive heart failure care, asthma care and cancer screening rates. Larger differences were found in preventive care for children less than 2 years of age, particularly for alternatively licenced physicians who entered Ontario from another Canadian province.

CONCLUSIONS

Our findings demonstrate that alternatively licenced physicians perform similarly to traditionally licenced physicians across many indicators of primary care. Our study also demonstrates the utility of administrative data for examining physician performance and evaluating medical regulatory policies and programmes.

[Competence-based assessment in the national licensing examination in Germany]

In Germany, future physicians have to pass a national licensing examination at the end of their medical studies. Passing this examination is the requirement for the license to practice medicine. The Masterplan Medizinstudium 2020 with its 41 measures aims to shift the paradigm in medical education and medical licensing examinations.The main goals of the Masterplan include the development towards competency-based and practical medical education and examination as well as the strengthening of general medicine. The healthcare policy takes into account social developments, which are very important for the medical education and licensing examination.Seven measures of the Masterplan relate to the realignment of the licensing examinations. Their function to drive learning should better support students in achieving the study goal defined in the German Medical Licensure Act: to educate a medical doctor scientifically and practically who is qualified for autonomous and independent professional practice, postgraduate education and continuous training.

Supply, distribution and characteristics of international medical graduates in family medicine in the United States: a cross-sectional study

Background

To describe the supply, distribution, and characteristics of international medical graduates (IMGs) in family medicine who provide patient care in the U.S.

Methods

A cross-sectional study design, using descriptive statistics on combined data from the Educational Commission for Foreign Medical Graduates and the American Medical Association, including medical school attended, country of medical school, and citizenship when entering medical school.

Results

In total, 118,817 physicians in family medicine were identified, with IMGs representing 23.8% (n = 28,227) of the U.S. patient care workforce. Of all 9579 residents in family medicine, 36.0% (n = 3452) are IMGS. In total, 35.9% of IMGs attended medical school in the Caribbean (n = 10,136); 19.9% in South-Central Asia (n = 5607) and 9.1% in South-Eastern Asia (n = 2565). The most common countries of medical school training were Dominica, Mexico, and Sint Maarten. Of all IMGs in family medicine who attended medical school in the Caribbean, 74.5% were U.S. citizens. In total, 40.5% of all IMGs in family medicine held U.S. citizenship at entry to medical school. IMGs comprise almost 40% of the family medicine workforce in Florida, New Jersey and New York.

Conclusions

IMGs play an important role in the U.S. family medicine workforce. Many IMGs are U.S. citizens who studied abroad and then returned to the U.S. for graduate training. Given the shortage of family physicians, and the large number of IMGs in graduate training programs, IMGs will continue to play a role in the U.S. physician workforce for some time to come. Many factors, including the supply of residency training positions, could eventually restrict the number of IMGs entering the U.S., including those contributing to family practice.

Moving beyond orientations: a multiple case study of the residency experiences of Canadian-born and immigrant international medical graduates

Many international medical graduates (IMGs) enter North American residency programs every year. The Canadian IMG physician pool increasingly includes Canadian-born IMGs (C-IMGs) along with Immigrant-IMGs (I-IMGs). Similar trends exist in the United States. Our objective was to understand the similarities and differences in the challenges faced by both I-IMGs and C-IMGs during residency to identify actionable recommendations to support them during this critical time. We performed a multiple case study of IMGs' experiences at a large Canadian university. Within our two descriptive cases (I-IMGs, C-IMGs) we iteratively conducted twenty-two semi-structured interviews; we thematically analyzed our data within, between, and across both cases to understand challenges to IMGs' integration and opportunities for curricular innovations to facilitate their adaptation process. Research team members with different perspectives contributed reflexively to the thematic analysis. Participants identified key differences between medical culture and knowledge expected in Canada and the health systems and curricula in which they originally trained. I-IMG and C-IMG participants perceived two major challenges: discrimination because of negative labelling as IMGs and difficulties navigating their initial residency months. C-IMGs described a third challenge: frustration around the focus on the needs of I-IMGs. Participants from both groups identified two major opportunities: their desire to help other IMGs and a need for mentorship. I-IMGs and C-IMGs face diverse challenges during their training, including disorientation and discrimination. We identified specific objectives to inform the design of curriculum and support services that residency programs can offer trainees as well as important targets for resident education and faculty development.

Experiential knowledge of risk and support factors for physician performance in Canada: a qualitative study

OBJECTIVE

To identify, understand and explain potential risk and protective factors that may influence individual and physician group performance, by accessing the experiential knowledge of physician-assessors at three medical regulatory authorities (MRAs) in Canada.

DESIGN

Qualitative analysis of physician-assessors' interview transcripts. Telephone or in-person interviews were audio-recorded on consent, and transcribed verbatim. Interview questions related to four topics: Definition/discussion of what makes a 'high-quality physician;' factors for individual physician performance; factors for group physician performance; and recommendations on how to support high-quality medical practice. A grounded-theory approach was used to analyse the data.

SETTING

Three provinces (Alberta, Manitoba, Ontario) in Canada.

PARTICIPANTS

Twenty-three (11 female, 12 male) physician-assessors from three MRAs in Canada (the College of Physicians & Surgeons of Alberta, the College of Physicians and Surgeons of Manitoba and the College of Physicians and Surgeons of Ontario).

RESULTS

Participants outlined various protective factors for individual physician performance, including: being engaged in continuous quality improvement; having a support network of colleagues; working in a defined scope of practice; maintaining engagement in medicine; receiving regular feedback; and maintaining work-life balance. Individual risk factors included being money-oriented; having a high-volume practice; and practising in isolation. Group protective factors incorporated having regular communication among the group; effective collaboration; a shared philosophy of care; a diversity of physician perspectives; and appropriate practice management procedures. Group risk factors included: a lack of or ineffective communication/collaboration among the group; a group that doesn't empower change; or having one disruptive or 'risky' physician in the group.

CONCLUSIONS

This is the first qualitative inquiry to explore the experiential knowledge of physician-assessors related to physician performance. By understanding the risk and support factors for both individual physicians and groups, MRAs will be better-equipped to tailor physician assessments and limited resources to support competence and enhance physician performance.

Specialty Board Certification Rate as an Outcome Metric for GME Training Institutions: A Relationship With Quality of Care

Educational outcome measures, known to be associated with the quality of care, are needed to support improvements in graduate medical education (GME). This retrospective observational study sought to determine whether there was a relationship between the specialty board certification rates of GME training institutions and the quality of care delivered by their graduates. It is based on 7 years of hospitalizations in Pennsylvania (N = 354,767) with diagnoses of acute myocardial infarction, congestive heart failure, gastrointestinal hemorrhage, or pneumonia. The 2,265 attending physicians were self-identified internists, and they completed their training in 59 institutions. The percentage of board-certified physicians from each training institution, excluding the physician herself or himself, was calculated and an indicator of whether it exceeded 80% was created. This was analyzed against inhospital mortality and length of stay, adjusted for patient/physician/hospital characteristics. There were significantly lower odds of mortality (adjusted Odd's ratio [OR] = .92, 95% CI [0.86, 0.98]) and log length of stay (adjusted OR = .98, 95% CI [.94, .99]) when the attending physician trained in a residency program with an 80% or greater certification rate. The results suggest that specialty certification rates may be a useful educational outcome for residency training programs.

Relationships Between the ACGME Resident and Faculty Surveys and Program Pass Rates on the ABIM Internal Medicine Certification Examination

PURPOSE

The Accreditation Council for Graduate Medical Education (ACGME) has surveyed residents since 2003, and faculty since 2012. Surveys are designed to assess program functioning and specify areas for improvement. The purpose of this study was to assess the association of the ACGME's resident and faculty surveys with residency-program-specific performance on the American Board of Internal Medicine (ABIM) certification exam.

METHOD

Data were available from residents and faculty in 375 U.S. ACGME-accredited internal medicine programs from the 2012-2013, 2013-2014, and 2014-2015 academic years. Analysis of variance and correlations were used to examine the relationship between noncompliance with ACGME program requirements as assessed by the resident and faculty surveys, and ABIM program pass rates.

RESULTS

Noncompliance reported on the resident and faculty surveys was highest for programs not meeting the ACGME program requirement of an 80% pass rate on the ABIM certification examination. This relationship was significant for overall noncompliance, both within the resident (P < .001) and faculty (P < .05) surveys, for many areas within the two surveys (correlations ranged between -.07 and -.25, and P values ranged between .20 and < .001), and for the highest levels of noncompliance across areas of the resident (P < .001) and faculty (P < .04) surveys.

CONCLUSIONS

ACGME resident and faculty surveys were significantly associated with ABIM program pass rates, supporting the importance of these surveys within the ACGME's Next Accreditation System.

UK nationals who received their medical degrees abroad: selection into, and subsequent performance in postgraduate training: a national data linkage study

OBJECTIVES

To compare the likelihood of success at selection into specialty training for doctors who were UK nationals but obtained their primary medical qualification (PMQ) from outside the UK ('UK overseas graduates') with other graduate groups based on their nationality and where they gained their PMQ. We also compared subsequent educational performance during postgraduate training between the graduate groups.

DESIGN

Observational study linking UK medical specialty recruitment data with postgraduate educational performance (Annual Review of Competence Progression (ARCP) ratings).

SETTING

Doctors recruited into national programmes of postgraduate specialist training in the UK from 2012 to 2016.

PARTICIPANTS

34 755 UK-based trainee doctors recruited into national specialty training programmes with at least one subsequent ARCP outcome reported during the study period, including 1108 UK overseas graduates.

MAIN OUTCOME MEASURES

Odds of being deemed appointable at specialty selection and subsequent odds of obtaining a less versus more satisfactory category of ARCP outcome.

RESULTS

UK overseas graduates were more likely to be deemed appointable compared with non-EU medical graduates who were not UK citizens (OR 1.29, 95% CI 1.16 to 1.42), although less so than UK (OR 0.25, 95% CI 0.23 to 0.27) or European graduates (OR 0.66, 95% CI 0.58 to 0.75). However, UK overseas graduates were subsequently more likely to receive a less satisfactory outcome at ARCP than other graduate groups. Adjusting for age, sex, experience and the economic disparity between country of nationality and place of qualification reduced intergroup differences.

CONCLUSIONS

The failure of recruitment patterns to mirror the ARCP data raises issues regarding consistency in selection and the deaneries' subsequent annual reviews. Excessive weight is possibly given to interview performance at specialty recruitment. Regulators and selectors should continue to develop robust processes for selection and assessment of doctors in training. Further support could be considered for UK overseas graduates returning to practice in the UK.

Are general practitioners characteristics associated with the quality of type 2 diabetes care in general practice? Results from the Norwegian ROSA4 study from 2014

OBJECTIVE

To explore the associations between general practitioners (GPs) characteristics such as gender, specialist status, country of birth and country of graduation and the quality of care for patients with type 2 diabetes (T2DM).

DESIGN

Cross-sectional survey.

SETTING AND SUBJECTS

The 277 GPs provided care for 10082 patients with T2DM in Norway in 2014. The GPs characteristics were self-reported: 55% were male, 68% were specialists in General Practice, 82% born in Norway and 87% had graduated in Western Europe. Of patients, 81% were born in Norway and 8% in South Asia. Data regarding diabetes care were obtained from electronic medical records and manually verified.

MAIN OUTCOME MEASURES

Performance of recommended screening procedures, prescribed medication and level of HbA1c, blood pressure and LDL-cholesterol stratified according to GPs characteristics, adjusted for patient and GP characteristics.

RESULT

Female GPs, specialists, GPs born in Norway and GPs who graduated in Western Europe performed recommended procedures more frequently than their counterparts. Specialists achieved lower mean HbA1c (7.14% vs. 7.25%, p < 0.01), a larger proportion of their patients achieved good glycaemic control (HbA1c = 6.0%-7.0%) (49.1% vs. 44.4%, p = 0.018) and lower mean systolic blood pressure (133.0 mmHg vs. 134.7 mmHg, p < 0.01) compared with non-specialists. GPs who graduated in Western Europe achieved lower diastolic blood pressure than their counterparts (76.6 mmHg vs. 77.8 mmHg, p < 0.01).

CONCLUSION

Several quality indicators for type 2 diabetes care were better if the GPs were specialists in General Practice. Key Points Research on associations between General Practitioners (GPs) characteristics and quality of care for patients with type 2 diabetes is limited. Specialists in General Practice performed recommended procedures more frequently, achieved better HbA1c and blood pressure levels than non-specialists. GPs who graduated in Western Europe performed screening procedures more frequently and achieved lower diastolic blood pressure compared with their counterparts. There were few significant differences in the quality of care between GP groups according to their gender and country of birth.

Awareness and Knowledge Among Internal Medicine Resident Trainees for Dose Adjustment of Analgesics and Neuropsychotropic Medications in CKD

OBJECTIVES

Errors in drug dosing lead to poor patient outcomes and are common in patients with chronic kidney disease (CKD). Because the majority of patients with CKD are being treated by physicians specializing in internal medicine, we studied the awareness and knowledge that internal medicine resident trainees (IMRTs) have regarding the correct dosage of commonly used analgesic and neuropsychotropic medications for patients with CKD.

METHODS

We surveyed 353 IMRTs about their awareness of whether a medication needs dose adjustment in patients with CKD and knowledge for medication adjustment by level of glomerular filtration rate.

RESULTS

There were high percentages for lack of awareness and knowledge. For analgesics, this lack of awareness/knowledge was highest for acetaminophen (awareness 83.0%, knowledge 90.9%). For neuropsychotropics, this was highest for paroxetine (awareness 74.5%, knowledge 91.5%). Analyses for postgraduate year (PGY) -1 trainees and PGY-2 trainees for analgesics showed higher odds for lack of awareness for tramadol (PGY-1 odds ratio [OR] 2.37, 95% confidence interval [CI] 1.2-4.62, P < 0.05; PGY-2 OR 2.34, 95% CI 1.16-4.72, P < 0.05) and for lack of knowledge for meperedine (PGY-1 OR 4.01, 95% CI 1.81-8.89, P < 0.05; PGY-2 OR 3.30, 95% CI 1.44-7.59, P < 0.05). Nephrology residency rotation for the neuropsychotropic medication of gabapentin showed lower odds for both lack of awareness (OR 0.56, 95% CI 0.32-0.97, P < 0.05) and knowledge (OR 0.52, 95% CI 0.27-0.997, P < 0.05).

CONCLUSIONS

Awareness and knowledge are poor among IMRTs for dose adjustments of analgesics and neuropsychotropic medication classes in patients with CKD. There should be a renewed focus during IMRTs' residency on additional nephrology exposure and formal didactic educational training to help them better manage complex treatment regimens to prevent medication dosing errors.

A Purpose-Driven Fourth Year of Medical School

The fourth year of medical school has been repeatedly found to be ineffective, and concerns exist about its purpose and academic quality, as well as grade inflation. Since Flexner, the purpose of undergraduate medical training has moved from readiness for independent practice to readiness for postgraduate training. However, training directors report that medical graduates are inadequately prepared to enter residency. The authors propose a fourth year with two components: first, a yearlong, longitudinal ambulatory experience of at least three days each week on an interprofessional team with consistent faculty supervision and mentoring, increasing independence, and a focus on education; and second, rigorous clinical-scales-based assessment of meaningful outcomes.In the proposed model, the medical student has generous time with a limited panel of patients, and increasing autonomy, with faculty moving from supervising physicians to collaborating physicians. There is regular assessment and formative feedback. This more independent, longitudinal clinical experience uniquely allows assessment of the most meaningful work-based performance outcomes-that is, patient outcomes assessed by validated clinical scales. The proposed fourth year will require a realignment of resources and faculty time; however, models already exist. Barriers and possible solutions are discussed.A purpose-driven, assessment-rich fourth year with patient and supervisor continuity will provide real-world experience, making medical graduates more competent and confident on the first day of residency. Use of clinical scales will also allow educators new confidence that the performance-based competence of these more experienced and expert graduates leads to demonstrable collaboration, healing, and good patient outcomes.

Patients of doctors further from medical school graduation have poorer outcomes

CONTEXT

There is an apparent contradiction between the findings of studies indicating that patient outcomes are better when physicians have a greater volume of practice and those that find outcomes to be worse with increased time since training, which implies greater volume.

OBJECTIVES

This study was designed to estimate the adjusted relationships between physicians' characteristics, including recent practice volume and time since medical school graduation, and patient outcomes.

METHODS

This is a retrospective observational study based on all Pennsylvania hospitalisations over 7 years for acute myocardial infarction, congestive heart failure, gastrointestinal haemorrhage, hip fracture and pneumonia. It refers to 694 020 hospitalisations in 184 hospitals attended by 5280 internists and family physicians. Patient severity of illness at admission and in-hospital mortality, hospital location and volume, and the physician's recent practice volume, time since medical school graduation, board certification, and citizenship or medical school location were analysed.

RESULTS

After adjustment, recent practice volume did not have a statistically significant association with in-hospital mortality for all of the conditions combined. By contrast, each decade since graduation from medical school was associated with a 4.5% increase in relative risk for patient mortality.

CONCLUSIONS

Recent practice volume does not mitigate the increase in patient mortality associated with physicians' time since medical school graduation. These findings underscore the need to finds ways to support and encourage learning.

Predicting fitness to practise events in international medical graduates who registered as UK doctors via the Professional and Linguistic Assessments Board (PLAB) system: a national cohort study

BACKGROUND

International medical graduates working in the UK are more likely to be censured in relation to fitness to practise compared to home graduates. Performance on the General Medical Council's (GMC's) Professional and Linguistic Assessments Board (PLAB) tests and English fluency have previously been shown to predict later educational performance in this group of doctors. It is unknown whether the PLAB system is also a valid predictor of unprofessional behaviour and malpractice. The findings would have implications for regulatory policy.

METHODS

This was an observational study linking data relating to fitness to practise events (referral or censure), PLAB performance, demographic variables and English language competence, as evaluated via the International English Language Test System (IELTS). Data from 27,330 international medical graduates registered with the GMC were analysed, including 210 doctors who had been sanctioned in relation to at least one fitness to practise issue. The main outcome was risk of eventual censure (including a warning).

RESULTS

The significant univariable educational predictors of eventual censure (versus no censures or referrals) were lower PLAB part 1 (hazard ratio [HR], 0.99; 95% confidence interval, 0.98 to 1.00) and part 2 scores (HR, 0.94; 0.91 to 0.97) at first sitting, multiple attempts at both parts of the PLAB, lower IELTS reading (HR, 0.79; 0.65 to 0.94) and listening scores (HR, 0.76; 0.62 to 0.93) and higher IELTS speaking scores (HR, 1.28; 1.04 to 1.57). Multiple resits at either part of the PLAB and higher IELTS speaking score (HR, 1.49; 1.20 to 1.84) were also independent predictors of censure. We estimated that the proposed limit of four attempts at both parts of the PLAB would reduce the risk in this entire group by only approximately two censures per 5 years in this group of doctors.

CONCLUSIONS

Making the PLAB, or any replacement assessment, more stringent and raising the required standards of English reading and listening may result in fewer fitness to practice events in international medical graduates. However, the number of PLAB resits permitted would have to be further capped to meaningfully impact the risk of sanctions in this group of doctors.

Quality of care delivered by general internists in US hospitals who graduated from foreign versus US medical schools: observational study

OBJECTIVE

 To determine whether patient outcomes differ between general internists who graduated from a medical school outside the United States and those who graduated from a US medical school.

DESIGN

 Observational study.

SETTING

 Medicare, USA.

PARTICIPANTS

 20% national sample of data for Medicare fee-for-service beneficiaries aged 65 years or older admitted to hospital with a medical condition in 2011-14 and treated by international or US medical graduates who were general internists. The study sample for mortality analysis included 1 215 490 admissions to the hospital treated by 44 227 general internists.

MAIN OUTCOME MEASURES

 Patients' 30 day mortality and readmission rates, and costs of care per hospital admission, with adjustment for patient and physician characteristics and hospital fixed effects (effectively comparing physicians within the same hospital). As a sensitivity analysis, we focused on physicians who specialize in the care of patients admitted to hospital ("hospitalists"), who typically work in shifts and whose patients are plausibly quasi-randomized based on the physicians' work schedules.

RESULTS

 Compared with patients treated by US graduates, patients treated by international graduates had slightly more chronic conditions. After adjustment for patient and physician characteristics and hospital fixed effects, patients treated by international graduates had lower mortality (adjusted mortality 11.2% v 11.6%; adjusted odds ratio 0.95, 95% confidence interval 0.93 to 0.96; P<0.001) and slightly higher costs of care per admission (adjusted costs $1145 (£950; €1080) v $1098; adjusted difference $47, 95% confidence interval $39 to $55, P<0.001). Readmission rates did not differ between the two types of graduates. Similar differences in patient outcomes were observed among hospitalists. Differences in patient mortality were not explained by differences in length of stay, spending level, or discharge location.

CONCLUSIONS

 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.

The role of assessment in supporting the movement toward patient-centred care

None

The Characteristics of International Medical Graduates Who Have Been Disciplined by Professional Regulatory Colleges in Canada: A Retrospective Cohort Study

PURPOSE

This study evaluated the proportion and characteristics of international medical graduates (IMGs) who have been disciplined by professional regulatory colleges in Canada in comparison with disciplined North American medical graduates (NAMGs).

METHOD

The authors compiled a database of the nature of professional misconduct and penalties incurred by disciplined physicians from January 2000 to May 2015 using public records. They compared discipline data for IMGs versus those for NAMGs, and calculated risk ratios (RRs) and 95% confidence intervals (CIs) for select outcomes.

RESULTS

There were 794 physicians disciplined; 922 disciplinary cases during the 15-year study period. IMGs composed an average of 23.4% (standard deviation = 1.1%) of the total physician population and represented one-third of disciplined physicians and discipline cases. The overall disciplinary rate for all Canadian physicians was 8.52 cases per 10,000 physician years (95% CI [7.77, 9.31]). This rate per group was higher for IMGs than for NAMGs (12.91 [95% CI (11.50, 14.43)] vs. 8.16 [95% CI (7.53, 8.82)] cases per 10,000 physician years, P < .01, and RR 1.58 (95% CI [1.38, 1.82]). IMGs were disciplined at significantly higher rates than NAMGs if they were trained in South Africa (RR 1.73 [95% CI (1.14, 2.51), P < .01), Egypt (RR 3.59 [95% CI (2.18, 5.52)], P < .01), or India (RR 1.66 [95% CI (1.01, 2.55)], P = .03).

CONCLUSIONS

IMGs are disciplined at a higher rate than NAMGs. Future initiatives should be focused to delineate the exact cause of this observation.