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Are US Patient Deaths Lower With Non-US-Trained Physicians?

  • Authors: News Author: Ricki Lewis, PhD; CME Author: Charles P. Vega, MD
  • CME / ABIM MOC / CE Released: 3/15/2017
  • Valid for credit through: 3/15/2018, 11:59 PM EST
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Target Audience and Goal Statement

This article is intended for nurses, pharmacists, and physicians who practice inpatient (hospital) medicine.

The goal of this activity is to provide medical news to primary care clinicians and other healthcare professionals in order to enhance patient care.

Upon completion of this activity, participants will be able to:

  1. Assess the proportion of international medical graduates (IMGs) in Western countries and the processes to approve practice of IMGs in these countries
  2. Compare outcomes of inpatient care between US medical school graduates and IMGs


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  • Ricki Lewis, PhD

    Freelance writer, Medscape


    Disclosure: Ricki Lewis, PhD, has disclosed no relevant financial relationships.


  • Robert Morris, PharmD

    Associate CME Clinical Director, Medscape, LLC


    Disclosure: Robert Morris, PharmD, has disclosed no relevant financial relationships.

CME Author(s)

  • Charles P. Vega, MD

    Health Sciences Clinical Professor, UC Irvine Department of Family Medicine; Associate Dean for Diversity and Inclusion, UC Irvine School of Medicine, Irvine, California


    Disclosure: Charles P. Vega, MD, has disclosed the following relevant financial relationships:
    Served as an advisor or consultant for: McNeil Consumer Healthcare
    Served as a speaker or a member of a speakers bureau for: Shire Pharmaceuticals

CME Reviewer/Nurse Planner

  • Amy Bernard, MS, BSN, RN-BC

    Lead Nurse Planner, Medscape, LLC


    Disclosure: Amy Bernard, MS, BSN, RN-BC, has disclosed no relevant financial relationships.

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Are US Patient Deaths Lower With Non-US-Trained Physicians?

Authors: News Author: Ricki Lewis, PhD; CME Author: Charles P. Vega, MDFaculty and Disclosures

CME / ABIM MOC / CE Released: 3/15/2017

Valid for credit through: 3/15/2018, 11:59 PM EST


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]

Study Highlights

  • Medicare databases were cross-referenced with datasets from the American Hospital Association and physician characteristics. Researchers focused on outcomes of Medicare beneficiaries 65 years and older admitted to the hospital with a medical condition between 2011 and 2014.
  • The primary study outcome was 30-day mortality rates after hospital admission. Researchers also followed 30-day readmission rates and Medicare part B (physician professional fees) spending on the admission.
  • The main study variable was training at an international medical school or US medical school. All physicians evaluated were trained in internal medicine and practiced primarily as hospitalists.
  • The study analysis was adjusted to account for patient sociodemographic and disease factors as well as physician age, sex, and patient volume. Researchers were able to compare US-trained physicians vs IMGs within the same hospital.
  • 44,227 physicians were included in the sample, of whom 44.3% were IMGs. Compared with US-trained physicians, IMGs were slightly younger as a group and were more likely to work in medium-sized, nonteaching, for-profit hospitals without intensive care units.
  • IMGs also cared for patients who were more indigent with higher degrees of comorbid illnesses.
  • 1,215,490 inpatients were included in the analysis of study outcomes. The overall 30-day mortality rate was 11.4%. The respective adjusted mortality rates for IMGs and US-trained physicians were 11.2% and 11.6% (adjusted OR, 0.96; 95% CI, 0.94-0.98).
  • IMGs had lower mortality rates for admissions for pneumonia and congestive heart failure specifically.
  • The rates of readmission at 30 days were slightly more than 15% for both IMGs and US-trained physicians, with no significant difference between groups.
  • However, the costs of care were slightly and significantly higher among IMGs compared with those of US-trained physicians.
  • Subgroup analyses based on hospital characteristics failed to significantly alter the main study outcomes, as did exclusion of physicians trained in Central America and the Caribbean, a large proportion of whom might have been raised in the United States.

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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