Clinical Context

Graduates of international medical schools are an important part of the healthcare system in many Western countries, and the authors of the current study provide a review of the role of international medical graduates (IMGs). They note that one-quarter of practicing physicians in the United States, United Kingdom, Canada, and Australia are IMGs. In the United Kingdom, most IMGs trained in India, the Republic of Ireland, or Pakistan, whereas in the United States, IMGs from India, Pakistan, and the Philippines are fairly common.

The United States requires that IMGs pass both United States Medical Licensing Examination (USMLE) Clinical Knowledge tests plus the USMLE Clinical Skills test before being permitted to practice medicine. Moreover, the US Educational Commission for Foreign Medical Graduates has stated a goal to accredit all foreign medical schools by 2023. In the United Kingdom, IMGs have to pass an examination of English proficiency and professionalism, but not examinations evaluating medical knowledge.

There is concern among stakeholders, including patients, that the care provided by IMGs is inferior to that of physicians trained in their country of practice. However, little data are available to validate this belief. In fact, some research has found that IMGs outperform US medical graduates on medical knowledge testing. The current study by Tsugawa and colleagues fills a gap in research by evaluating outcomes of inpatients cared for by US-trained physicians and IMGs in the United States.

Study Synopsis and Perspective

Medicare patients admitted to the hospital and treated by internists who graduated from medical schools outside the United States had lower 30-day mortality rates than matched patients cared for by graduates of US schools, according to results of a study published online in the BMJ.

To practice in the United States, international medical school graduates must pass 2 examinations on medical knowledge and 1 assessment of clinical skills, and complete accredited residency training here. However, medical schools outside the United States are not accredited by any domestic agency. In response to concerns about quality of care from internationally trained physicians, the Educational Commission for Foreign Medical Graduates will require accreditation of medical schools outside the United States by 2023.

Studies comparing the quality of care provided by internationally trained physicians with that by domestically trained physicians are few and small in scope. Yet, physicians trained outside the United States may be perceived by some as not as competent as physicians who attended medical school in the United States.

To compare the two, Yusuke Tsugawa, MD, PhD, from the Harvard TH Chan School of Public Health, Boston, Massachusetts, and colleagues conducted a large observational study of hospitalized Medicare beneficiaries to assess whether outcomes differ depending on whether their general internists were trained domestically or abroad. The study excluded graduates from Central America and the Caribbean to minimize inclusion of US citizens trained outside the country. The countries that contributed the most internists to US hospitals were China, Egypt, India, Mexico, Nigeria, Pakistan, the Philippines, and Syria.

The researchers assessed 30-day mortality rate (the primary outcome), readmission rate, and costs of care (total part B spending), and whether clinical condition influences differences in patient outcomes and care costs between the 2 groups of patients. In addition, they adjusted their models for patient characteristics (age, sex, race or ethnic group, diagnosis, and income), physician characteristics (age, sex, and patient volume), and hospital fixed effects (characteristics of hospitals).

Results indicated that 19,589 (44.3%) of 44,227 general internists in the United States graduated from medical schools outside the country. They were slightly younger than US graduates (age 46.1 vs 47.9 years; P <.001) and were more likely to work in medium-sized, nonteaching, for-profit hospitals without intensive care units.

In addition, their patients were more likely to be nonwhite, have Medicaid, have a lower median household income, and have more chronic comorbidities (congestive heart failure, chronic obstructive pulmonary disease, and diabetes).

The mortality analysis included 1,215,490 patients admitted to the hospital under the care of 44,227 general internists between 2011 and 2014. Patients treated by international graduates had lower mortality rates (adjusted mortality rate, 11.2% vs 11.6%; adjusted odds ratio [OR], 0.95; 95% confidence interval [CI], 0.93-0.96; P <.001).

"Based on the risk difference of 0.4 percentage points, for every 250 patients treated by US medical graduates, one patient's life would be saved if the quality of care were equivalent between the international graduates and US graduates," the authors write.

The cost analysis included 1,276,559 patients treated by 44,680 physicians during the same study period.

Overall, patients of internationally trained internists had slightly higher adjusted costs of care per admission ($1145 vs $1098; adjusted difference, $47; 95% CI, $39-$55; P <.001).

Meanwhile, adjusted readmission rates among 1,182,268 patients who were treated by 44,201 physicians did not differ between the 2 patient groups.

When the researchers examined 30-day mortality in patients with 1 of 6 conditions (sepsis, pneumonia, congestive heart failure, chronic obstructive pulmonary disease, urinary tract infection, and arrhythmia), they found that patients receiving care from international graduates had lower mortality rates than did patients of US graduates for pneumonia and congestive heart failure.

"Taken together, our findings should reassure policymakers and the public that our current approach to licensing international medical graduates in the US is sufficiently rigorous to ensure high quality care," the researchers conclude.

They suggest that the testing process may select for the top international medical school graduates. The fact that some internationally trained internists may have completed 2 residencies (one in the home country and one here) might also contribute to the slightly better mortality outcomes of their patients.

A limitation of the study was the inability to assign patient outcomes to physicians from individual countries.

The researchers have disclosed no relevant financial relationships.

BMJ. Published online February 2, 2017.^[1]

Clinical Implications

• One-quarter of practicing physicians in major Western countries are IMGs. IMGs have to pass USMLE examinations to practice in the United States, whereas English-language proficiency among these physicians is stressed in the United Kingdom. The US Educational Commission for Foreign Medical Graduates has stated a goal to accredit all foreign medical schools by 2023.
• The current study by Tsugawa and colleagues demonstrates that mortality rates were slightly lower among older adults treated by IMG hospitalists vs US-trained hospitalists. Costs of care by IMGs were slightly higher than those of US-trained physicians, and there was no difference between the 2 cohorts of physicians in readmission rates.
• Implications for the Healthcare Team: The current study should help dispel the notion that IMGs provide worse medical care compared with US medical graduates. The study results may be used by hospitals and health systems to create awareness about IMGs and their qualifications as clinicians.

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