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In this first of a two-part series, we examine the implications of international medical graduates (IMGs) in hospital medicine groups, and explore how hospitalist group leaders can improve communications and integrate them into their medicine teams. Part 2 will feature stories from hospitalist IMGs as they establish themselves as professionals in their communities.

International medical graduates (IMGs) comprise 25% of the total U.S. physician workforce.1 Despite post-9/11 barriers to immigration, the number of IMGs entering internal medical residencies has risen in recent years.

In 2006, more than 6,500 physicians who graduated medical school in foreign countries entered accredited residency programs, according to the Association of American Medical Colleges. U.S.-born residents who have attended medical school in another country account for approximately 25% of the total IMGs in training.

Further, the proportion of foreign-educated residents who will go into primary care is higher than for U.S. medical graduates. In 2006, 50% of the physicians training in internal medicine residency programs were IMGs.

What do these trends mean for hospital medicine? In light of projected physician shortages IMGs will continue to be a vital part of the physician workforce.2 Because internal medicine is a primary feeder of hospital medicine, it’s likely many hospital medicine programs will also continue to see an increase in hospitalists who are IMGs.

Hoops, Hurdles, and Visas

Entry of foreign-born IMGs to the United States is governed by the Immigration and Nationality Act, administered by the U.S. Immigration and Naturalization Service.

The J-1 visa was set up as an educational exchange program and carries with it a requirement that the graduate return to his or her native country upon completion of residency. However, a waiver of the requirement to return to their country of origin can be obtained if the physicians agree to begin practice in a Health Professional Shortage Area.

These service areas are determined using a scoring system based on four variables: the ratio of primary medical care physicians per 1,000 population, infant mortality rates, percentage of the population with incomes below the federal poverty level, and percentage of the population over 65. The vast majority of J-1 waivers are administered through “Conrad 30” programs administered by individual states and the District of Columbia.

In recent years, AAMC’s Center for Workforce Studies has observed a shift to the H1-B, or temporary worker visa, allowing hospitals and group practices to hire IMGs in areas where there are physician shortages. This visa is employer-specific, and some hospitalist programs have become involved in helping their applicants secure this visa.

Visa issues present a range of financial, legal and personal hurdles for the IMG. In addition to obtaining legal entry into the country, IMGs applying to U.S. residency programs must obtain ECGMG certification, a multistep process that includes:

  • Graduating from a medical school listed in the World Directory of Medical Schools;
  • Obtaining a license to practice medicine within their own country;
  • Passing the medical science examination (Step 1 and 2 of the United States Medical Licensing Examination);
  • Passing the ECFMG English test or Test of English as a Foreign Language; and
  • Passing the Clinical Skills Assessment component of the USMLE.

An IMG can apply for lawful permanent resident status based on a job offer, provided that he or she has passed parts 1 and 2 of the National Board of Medical Examiners examination, and has fulfilled the other ECFMG certification requirements.

For more information, visit the Web sites of the Accreditation Council for Graduate Medical Education (www.acgme.org) and the Educational Commission for Foreign Medical Graduates (www.ecfmg.org).—GH

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