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The New Physician October 2001
For more than a decade, Dr. John Madden has been taking care of patients. When he first meets them, the usual small talk ensues with brief discussions about the weather or family life. And then on the rare occasion, a patient will ask him where he received his medical degree. He quickly replies, “St. George’s University.” The patient sometimes follows up with additional questions, but more often than not, the patient will shrug his shoulders and the exam will continue.

“Patients rarely ask about what school I went to, and when they do, they just think it’s a U.S. school they’ve never heard of,” says Madden, the associate chairman of the Emergency Medicine Unit of Christiana Care Hospital System in Newark, Delaware. “Patients just really don’t care about that.”

St. George’s is a medical school in Grenada and sends the majority of its graduates into the U.S. medical system. That makes Madden an international medical graduate, also known simply as an IMG.

However, this label means very little to patients and many fellow health-care professionals. Once you’ve established yourself as a physician, where you received your degree often becomes a non-issue, most IMGs say. “It has always been that the proof is in the pudding,” says Madden, who received his medical degree in 1981. “If you are a good clinician, then you’re a good clinician.”

But where you receive your degree is an issue during your medical training. For decades, IMGs have been the center of debate and controversy in the medical education community. Critics have questioned the quality of education that IMGs receive and argued that they’re contributing to a physician glut in the United States. The concerns were in part perpetuated by a 1991 report by the Educational Commission for Foreign Medical Graduates (ECFMG), the organization responsible for verifying the credibility of foreign medical degrees. The report indicated that IMGs scored significantly lower on medical licensing examinations than their U.S. counterparts. And while IMG scores have improved substantially, they continue to lag scores of U.S. graduates.

The reputation of IMGs was previously muddied when two Caribbean medical schools were shut down in the mid-1980s after being implicated for producing counterfeit diplomas. And then in 1992, the U.S. General Accounting Office discovered a school in the Dominican Republic granting worthless degrees.

These problems contributed to a negative image of all foreign medical schools and their graduates. “From the majority of my American colleagues, I heard that foreign medical schools were second-rate, and that I might find it difficult to obtain a good residency in the U.S.,” says Benjamin Davis, a second-year student at Ross University School of Medicine in Dominica and the international trustee for the American Medical Student Association (AMSA).


However, time has slowly begun to erase images of fraudulent foreign medical schools, and it is becoming increasingly difficult to place these general criticisms on every medical student who has completed his preclinical work at one of the approximate 1,400 medical schools outside of the United States, its territories and Canada. IMGs have come to represent a group of physicians with diverse backgrounds and varied educational and clinical experiences.

“A lot of [the criticism] is not true and does not differentiate graduates’ nationality and where they went,” says Dr. Seth Tuwiner, a graduate of the Technion School of Medicine in Israel and a neurology resident at the University of Southern California. “The success of a foreign grad is a function of nationality, school, whether or not this person has done rotations in the U.S., connections, research experience, board scores. We are all not in one category.”

In reality, international medical graduates are just as diverse and unique as their U.S.-educated counterparts. Within the IMG group, there are U.S. IMGs, who are U.S. citizens or permanent residents; FNIMGs, or foreign national IMGs, who are not U.S. citizens and obtained their degrees at schools not approved by the Liaison Committee on Medical Education (LCME); and EVIMGs, or exchange visitor IMGs, who are physicians temporarily in the United States, often with J-1 visas, to study, teach or do research. And of course, all of these IMG subsets can be broken down further based on the type of education they received and, more importantly some IMGs argue, the type of clinical rotations they have done.

Regardless of their definition, there is little question that IMGs make up a significant part of the U.S. medical community. In 1998, they accounted for more than 176,000 physicians practicing in the United States, which represented approximately 23 percent of all physicians. They also accounted for nearly 24 percent of residents, including 37 percent of interns.

In the 2002 Match, more than 6,500 IMGs submitted rank-order lists to be placed in U.S. residency programs. Of those applicants, 52 percent were matched with a program of their choice. With more than 3,000 IMGs serving as first-year residents, their impact on U.S. health care is unquestionable.

And that number is deceivingly low, according to Dr. Thomas Moore, president of the American Association of International Medical Graduates. “There are also a substantial number of [residency] programs that sign up IMGs outside of the Match,” Moore says. “We estimate roughly that there are currently between 6,000 to 7,000 surplus residencies in the United States not filled by U.S. graduates. IMGs, osteopathic grads and a small percentage of Canadians fill these gaps.”

In fact, foreign medical graduates’ supporters argue IMGs have become necessary to U.S. medicine because they typically provide health care to underserved areas and at the primary-care level, which is frequently overlooked by U.S. graduates who favor more lucrative practice settings.


When it comes to their qualifications, IMGs point to the rigorous standards of the ECFMG, which ensure that all foreign medical graduates meet the qualifications necessary to enter residencies in the United States.

“ECFMG certification provides assurance to directors of graduate medical education [GME] programs, and to health-care consumers in the U.S., that IMGs have met the minimum standards of eligibility to participate in GME programs and to provide supervised patient care,” says Dr. James Hallock, ECFMG’s president and CEO. “This process of certification is the reason ECFMG was established and remains the organization’s primary mission.”

To be certified by the ECFMG, IMGs must pass Step 1 and Step 2 of the United States Medical Licensing Examination, just like their U.S. counterparts. But in addition, IMGs must also pass the Test of English as a Foreign Language, and a clinical skills assessment exam—expected to be required of third-year U.S. medical students beginning in 2004—and have their medical diplomas verified by the ECFMG.

“Since ECFMG certification is a requirement for licensure of IMGs in nearly all U.S. jurisdictions, there are differences in licensure requirements for IMGs and U.S./Canadian medical graduates,” Hallock says. “However, each component in the certification process is important in evaluating IMGs’ qualifications.”

And all IMGs must meet these requirements, regardless of whether they are U.S. citizens or citizens of other nations, and regardless of whether or not English is their first language. But beyond passing standardized tests, there remain many variables among IMGs.


The most common stereotype of an IMG is that of an FNIMG, someone of foreign nationality who received his education in his home country and then came to the United States to complete a residency or a fellowship and maybe looks to remain here. Certainly, there is a segment of the IMG population that matches this perception. In fact, almost half of all IMGs in U.S. residency programs are citizens of foreign countries, while 92 percent of the rest of IMG residents have become naturalized citizens or permanent residents in the United States.

As a result, several associations have been formed to work on behalf of foreign-born IMGs as they attempt to make their way through the U.S. medical system—organizations such as the American Association of Physicians of Indian Origin; the Chinese American Medical Society; the Venezuelan American Medical Association; and the American College of International Physicians (ACIP), an umbrella advocacy organization for all IMGs, but particularly those of foreign descent.

Many of these organizations were created, in part, to help IMGs battle discrimination within the U.S. medical community. Many residency programs will not accept IMGs despite federal law—the Health Professions Education Extension Amendments of 1992—preventing such discrimination. In part, it’s because selection committees believe it’s more difficult to evaluate IMGs; however, their evaluation capabilities have been improved by the ECFMG certification standards.

“We were created just to protect our members or to be the spokesman for foreign medical graduates,” says Dr. Alberto René Maldonado, the chairman of the ACIP. “Over the years, there has been some legally resolved discrimination. At one time we had a wing that specialized in anti-discrimination litigation to protect IMGs.”


The best method for an IMG to obtain a residency in the United States is if his school has a prior relationship with the program. For example, several programs in New York, New Jersey and California have developed confidence in certain foreign medical schools, which makes it easier for selection committees to believe they are receiving a well-prepared graduate.

Without this type of relationship, it can be difficult for IMGs to obtain U.S. residency positions. Out of desperation, some foreign medical graduates accept unfunded positions referred to as “externships.”

Even once a residency position has been obtained, an FNIMG must become a permanent resident or work as an EVIMG, which requires him to obtain a visa. Often, these IMGs will pursue a J-1 visa, which is restricted to the time typically required to complete a residency. Approximately one-third of IMGs are working on J-1 visas, while another 8 percent hold H-1B visas for temporary employment.


“For foreign grads and U.S. foreign grads, it really is different,” Madden says. “They have visa problems and sometimes they have to sit out a year before getting a residency. For U.S. IMGs, there really hasn’t been a problem.”

Most of the obstacles facing U.S. IMGs occur when they made the decision to attend medical school. In many cases, U.S. IMGs were students who failed to get into U.S. medical schools because of insufficient grade-point averages or poor performances on the Medical College Admission Test (MCAT). Many of them dismiss the requirements as not being true tests of their abilities and look to other avenues to obtaining medical degrees.

That was the case for Angela Markman, who is in her second year at Ross. After receiving disappointing scores on the MCAT, she was unable to get accepted by a U.S. school. Markman was counseled by her adviser at New York University to investigate foreign institutions. “While I was considering the idea, I began volunteering in several hospitals as I took a year off after graduating…,” Markman says. “I started speaking to residents from the hospitals, and I was surprised to learn that many of them were either [from] St. George’s or from Ross University School of Medicine.”

Like many students considering a foreign medical education, Markman had doubts. “Some physicians, I would overhear, would speak negatively about foreign schools,” she says. “And, of course, there was the initial stigma from students, some of who felt that a foreign medical school would be their last resort or would not even be an option for them.

“I honestly believe that I am getting the same opportunity that other students are being offered in U.S. medical schools,” she says. “I had the opportunity to speak with many [U.S. medical school students]…and we all use the exact same textbooks, we all have the same classes, and we all take the same boards to practice in the U.S.”

Of course, these similarities aren’t coincidences. Administrators at Ross, St. George’s, the American University of the Caribbean in the Netherlands Antilles, the Universidad Autonoma de Guadalajara in Mexico and several other “offshore” medical institutions attempt to duplicate the U.S. educational model in order to help their graduates acquire clinical rotations in U.S. teaching hospitals.

“We are a bit of a hybrid because so much of our curriculum is here in the United States,” says Timothy Foster, the CEO and chairman of Ross. “The fact of the matter is that the only element of our education that is outside of the United States is our preclinical sciences program, all of which is 16 or 17 months of a four-year effort. All of the clinical sciences program is in the United States, not just the U.S. model but with U.S. faculty and often side by side with U.S. students of U.S. medical schools.”


However, some in the medical community still question the credibility of foreign schools and the validity of their clinical rotations.

In the May 2000 New England Journal of Medicine, Dr. Jordan Cohen of the Association of American Medical Colleges called for measures to increase oversight of U.S.-based educational programs that provide rotations to students of foreign medical schools.

International medical institutions sometimes arrange for their students to do clinical clerkships at U.S. institutions by making payments to the hospitals on a capitation basis. Cohen argues that education is perverted through this arrangement and that IMGs might not receive true experiences and evaluations. “I think that is a reasonable concern in the absence of any oversight,” he writes.

However, other foreign medical schools have received the stamp of approval of the state medical boards in New York, New Jersey, Florida and California. These boards formally sanction the graduates of some schools and approve their participation in clinical rotations at teaching hospitals in those states. “For the most part, anyone who has anything to do with academic medicine has a healthy respect for our graduates,” says Margaret Lambert, a dean at St. George’s, a university receiving state approvals. “You still have pockets of prejudice here and there, but…we have made a lot of inroads.”


Throughout the years, critics have voiced concerns over the quality of education at “offshore” schools and the lack of oversight by local authorities.

Cohen argues that, under the oversight of the LCME, U.S. medical schools must specify educational objectives, organize their programs and resources to accomplish these objectives, and develop procedures to measure the effectiveness of accomplishing their goals. These requirements provide assurances of educational standards beyond what can be measured in a licensing exam, Cohen says. “LCME standards for accreditation establish an academic context…and specify such requirements as the academic cohesion of the faculty, centralized design and management of the curriculum, functional integration of geographically separate campuses, evidence that dispersed educational experiences are similar in educational quality, and evidence that the medical school controls its academic programs in affiliated hospitals,” he writes. “Although a few other countries are currently developing an American-style system of accreditation, most countries largely sidestep assessment of the educational process and merely accept graduation from a medical school as sufficient evidence of preparedness for practice.”

However, “offshore” medical school administrators dispute this, arguing that the U.S. Department of Education’s National Committee on Foreign Medical Education and Accreditation reports that 26 other countries implement accreditation standards comparable to U.S. standards—findings Cohen and others disagree with. Among those countries are several “offshore” nations, such as Costa Rica, Dominica, the Dominican Republic, Grenada and Mexico.

Administrators also defend their for-profit structure. “Any institution, whether it’s for-profit or not-for-profit, is required to generate a return on capital,” Ross’ Foster says, and he takes the argument a step further by saying that foreign medical schools have the opportunity to provide a better education by focusing solely on teaching.

“All we do is teach,” he says. “We do not operate our own clinical facilities, neither inpatient or outpatient, except for services that we render to students on the preclinical sciences campus. And that, of course, is a huge burden on American medical education today.” Foster says clinical operations have become a financial drain on many U.S. medical schools, which are now trying to spin off those services onto other institutions. And, he argues, U.S. medical schools are further burdened by overemphasizing research, which, rather than teaching, is a major tool in evaluating and promoting faculty. “We do one thing: We teach,” he says.


While the debate may continue over the credibility of some foreign institutions, other medical schools are better regarded by the U.S. medical community. In fact, some U.S. IMGs were invited to attend medical school in their home country but simply thought they had better opportunities abroad.

“There are a number of international schools that would meet and exceed many U.S. schools, especially in places like Australia, England, Israel and Ireland…. These countries have very high standards of medical education and very high standards of clinical care,” says Mark Escott, a third-year medical sciences student at Flinders University in Australia. “Then again, there are many that would not be up to standards. Just like any other school, they should be considered on a case-by-case basis.”

In fact, graduates from Israel, Australia, Great Britain, Ireland, Mexico and other nations are routinely accepted into top-notch U.S. residencies. Some U.S. premed advisers even remark on the quality of these schools. For example, the University of Stony Brook declares on its Web site that some foreign institutions are “strong players in the field.”

“In a number of cases,” the Web site advises students, “admissions [to these schools] might be almost as competitive or just as competitive as admission to U.S. allopathic or osteopathic medical schools—even though criteria could vary in subtle ways. Are there students who have studied at foreign medical schools that are not listed…who have gone on to become good doctors? Yes, absolutely! Are there students who regret rashly made decisions regarding their education? Yes, unfortunately. So, research all of your options carefully, and make a decision that you are willing to live with, even if not everything goes according to plan.”


It’s becoming more difficult to summarily dismiss IMGs, particularly when they have obtained prominent positions throughout the U.S. medical community. From department heads at major hospitals to celebrated social activists, IMGs have become leaders in U.S. medicine. Even Dr. Elias Zerhouni, the recently appointed head of the National Institutes of Health (NIH), obtained his degree at a foreign medical school, the University of Algiers School of Medicine. However, he says his peers don’t see him as an IMG, but as a physician.

“It doesn’t matter who you are or where you come from,” he says. “What counts is what you do. Actions speak louder than diplomas.”

Regardless of whether they’re working for the NIH or a rural hospital in Kentucky, IMGs believe the time has come to look at their individual performances and their commitments to help their patients.
“I believe that the determination, resilience and success of many IMGs, from any sub-group, is worth noting,” AMSA’s Davis says. “Of course we might point to the high-profile success stories, but the fact that many students endure the added challenges, certification requirements and potential stigma in order to contribute significantly to American health care should be recognized.”
Scott T. Shepherd is an associate editor with The New Physician.