Part 1 why has the U.S. experienced such difficulty? - medical staffing in underserved areas persists

Physician Executive, Nov-Dec, 1998 by Thomas P. Weil

3. International medical graduates

Since the end of World War II, the use of international medical school graduates to meet the health needs of the underserved has been a thorny and frequently discussed issue that embraces some highly politicized ramifications.

Until relatively recently, what has thwarted limiting the increasing number of graduates of foreign medical schools from entering U.S. residency programs are such questions as: Who will care for the millions of uninsured who live in our inner-cities and who depend on large, privately or publicly-sponsored teaching hospitals for their health services? And, what would be the impact on the delivery of America's rural health care services, if such communities were no longer able to recruit graduates of foreign medical schools?

For nearly 50 years, the United States, with its advanced medical education system, has assumed the responsibility to train the brightest young physicians from less developed countries. Thereafter, international medical graduates (IMGs) have been expected to take their new knowledge back to their own countries--although few in recent years have returned home permanently. (17-18) 1MG training far better serves individual doctors and a few teaching hospitals ( since these foreign medical school graduates can be among the finest residents at these inner-city hospitals) than it does the countries from which they emigrated and where their earlier undergraduate medical education was subsidized. Should the richest country in the world drain underdeveloped countries of some of their most talented professionals?

Foreign medical school graduates in 1994 represented 23 percent (149,082 MDs) of the actively practicing physicians in the United States and this percentage is projected to increase. Since the early 1980s, the number of graduates of U.S. medical schools has remained relatively stable at about 17,000 per year, while the IMGs have filled an additional number of U.S. residency positions. The number of residents in U.S. allopathic hospitals, who graduated from a foreign medical school, increased from 11,556 in the 1988-89 academic year to 26,763 in 1995-96.

As this IMG debate has heated up, a wide range of medical, hospital, community, private foundation, and political groups, some laden with self-interest and often with competing agendas, are represented in a controversy as outlined below of whether to curtail the flow of IMG residents:

* Medicare is possibly the most crucial element in this discussion of IMGs, because this program has made payments for graduate medical education (combined payments from all third-party payers of an estimated $190,000/annum per resident are available in New York state) and until recently set no limits on the number of residents it would support at a specific institution. Enacted in 1965 with the major objective of financing health services for the aged, this federally-sponsored program has generated significant additional funding to teaching hospitals by making direct medical education payments for residents' stipends, faculty salaries, related administrative expenses, institutional overhead allocated to residency programs. and indirect medical education adjustments to per-case payments.