Utilizing the IMG workforce in the U.S.

The U.S. physician workforce includes allopathic physicians, osteopathic physicians and international medical graduates (IMGs), which are grouped based on their medical education.

IMGs are physicians who received their medical school education outside the United States or Canada. They comprise both U.S. citizens (U.S. IMGs) and citizens of foreign countries (non-U.S. IMGs) who have trained abroad, and they are important segments of the physician population. Today, 1 in 4 physicians practicing in the United States is trained at a foreign medical school; consequently, IMGs play a crucial role in our health care system.

The United States’ need for overseas medical schools to train physicians is likely to continue. This article summarizes available data regarding IMGs in training and in practice as it relates to physician recruitment.

IMGs’ critical role in overcoming the physician shortage

The physician recruitment industry in the United States faces a dilemma of unimaginable proportions in trying to staff the needs of many communities based solely on a workforce of American Medical Graduates (AMGs). Simply put, there are just not enough of them being produced to meet the need. As a result, many recruitment professionals find themselves looking at a vast array of IMGs to fill their open spots. However, many recruiters struggle with the concept of the IMG. Questions arise as to their training, their qualifications, their immigration standing and other aspects.

IMG graduates represent 26% of physicians in practice in the U.S. and 24% of all residents in specialty training.

IMG additional licensing and credentialing requirements

For an IMG physician to enter the U.S. workforce, several requirements need to be satisfied. He or she must go through a systematic process of evaluation and credentialing to ensure that all physicians have the same level of training regardless of the place of origin of training. At the core of this process is the Educational Commission for Foreign Medical Graduates (ECFMG). This body was established by six major regulatory, medical and educational entities dealing with physician workforce issues:

• The American Board of Medical Specialties
• The American Medical Association
• The Association of American Medical Colleges (AAMC)
• The Association for Hospital Medical Education
• The Federation of State Medical Boards
• The National Medical Association

Certification has been issued from the ECFMG since 1958 and is the standard for establishing the equivalence of qualifications of IMGs. Accordingly, all lMGs must obtain ECFMG certification before they qualify to enter a graduate medical education (GME) program in the United States. Certification from the ECFMG is also a requirement for medical licensing, as it is a prerequisite for taking the United States Medical Licensing Examination Step 3.

ECFMG’s program of certification assesses whether international medical graduates are ready to enter U.S. GME programs that are accredited by the Accreditation Council for Graduate Medical Education (ACGME). ACGME requires ECFMG certification for international medical graduates who enter such programs. ECFMG certification assures directors of accredited residency and fellowship programs, and the people of the United States, that international medical graduates have met minimum standards of eligibility to enter such programs.

Currently, international medical schools are not required to follow a standardized system of accreditation, though they may already follow local or international guidelines as part of their operation. This setup is likely to change, as the ECFMG has announced that by 2023, students who are seeking ECFMG certification should graduate from a properly accredited medical school. Such an accreditation process should include criteria similar to those used by the Liaison Committee on Medical Education in the United States or criteria accepted by the World Federation for Medical Education.

International medical school quality varies

International medical schools often carry with them doubts of their credibility and reputation. This Washington Post perspective piece, though, outlines why it’s unfair to judge all international medical schools the same.

For example, according to the article, 96% of U.S. or Canadian medical school students passed the U.S. Medical Licensing Examination on the first try in 2016 compared to 78% of students from schools elsewhere. However, some individual international schools rank much higher than others. In 2015, 97% of students at the University of Queensland’s Ochsner Clinical School in Australia passed Step 1 of the exam on the first try. At St. George’s University in Grenada, 96% passed in 2016.

Physician demand to grow

As the Washington Post article states, IMGs may likely be a primary solution for overcoming the projected physician shortage.

According to the AAMC, the demand for physicians is projected to grow 26.3% between 2006 and 2025, from 680,500 to 859,300 full-time equivalent positions. Most of this projected demand increase is attributable to the projected growth and aging of the population, especially the former. In fact, only about one-third of the projected rise in demand will be attributable to the aging of the population. Most of the increase in demand from the older population will come from the increase in their sheer numbers, rather than the shift in the age structure of the population – at least between now and 2025.

AAMC further posits the following implications in the workforce planning of physician utilization in the U.S.:

1. If U.S. MDs continue to select other specialties, the future of primary care practice is likely to rely increasingly on foreign medical school graduates, osteopaths and non-physician clinicians.
2. The demand projections are likely a conservative estimate. All signs suggest that baby boomers - and most following generations - will be aggressive about seeking care that will allow them to remain active, and that they will be more likely to seek medical care than previous generations.
3. Over the next several years, there are several factors that could worsen the shortage significantly. For example, if the nation does not implement significant delivery system reforms and/or improve efficiency and effectiveness, or if the nation moves rapidly toward universal health coverage, or if the flow of IMGs slows significantly, then any shortages that develop may be even more severe than those described in the report.
4. Given the evidence that IMG physicians are more likely to provide care for poor and underserved communities, increasing the diversity of the physician workforce should continue to be a priority of the medical education community (and physician recruitment across the country.)

Be prepared to tap into IMGs

Whether you’re a new physician recruiter or a seasoned veteran, IMGs, visas and immigration laws are topics you may need to acquaint yourself with going forward.

Understanding and strategizing about IMGs in your workplace will, at some point, become part of your everyday physician recruitment activities. Here are a few things to remember when considering IMGs for practice settings in the U.S.

To practice in the U.S., IMGs must:

1. Pass Steps 1 & 2 of the United States Medical Licensing Exam.
2. Get certified by the Educational Commission for Foreign Medical Graduates.
3. Complete a residency or fellowship program in the U.S. (regardless of whether they have already completed one in their home country - with the exception of Canada, where most residency programs are recognized in the U.S.)

In summary, the IMG population of physicians plays a vital role in the momentum and stability of the U.S. health care system. The likelihood of that key interface declining or being eliminated is remote. Practices, hospitals and groups will have to face the inevitability that IMGs are a segment of the workforce that must be considered as the baby-boomer generation develops a voracious appetite for health services.

As physician recruitment professionals, we are charged with the responsibility to avail our employers of all remedies present in today’s market.

Steven Jacobs, MA CPRP is the Manager of Physician recruitment at Einstein Healthcare Network and the President of the Mid-Atlantic Physician Recruiter Alliance (MAPRA).