Tuesday, August 3, 2010

Do non-citizen foreign medical graduates do it better?

Yes, according to a study in today's Health Affairs. (The full text of the study is available only to subscribers, but Kaiser Health News Daily has a good summary of its findings and links to other news reports.)

The study compares inpatient death rates and lengths-of-stay for patients with congestive heart failure or acute myocardial infarction when provided by U.S. citizens trained abroad, citizens trained in the United States, and non-citizens trained abroad. Treatment was provided by internists, family physicians, or cardiologists. The differences were striking, according to the authors:

"Our analysis of 244,153 hospitalizations in Pennsylvania found that patients of doctors who graduated from international medical schools and were not U.S. citizens at the time they entered medical school had significantly lower mortality rates than patients cared for by doctors who graduated from U.S. medical schools or who were U.S. citizens and received their degrees abroad."

It also found that board certification was positively associated with lower mortality and lengths of stay. Years in practice since graduation are associated with poorer outcomes. Self-designated cardiologists had higher mortality rates but lower lengths of stay than self-designated general internists and family physicians.

John Norcini, the study's co-author, tells Bloomberg news that "economics may help explain the gap in patient outcome." Because of lower pay relative to other specialties "primary care may not be getting the best and the brightest from U.S. medical schools," said Norcini. "Foreign students see primary care as a gap that they can fill and a way to practice medicine here." He calls non-citizen IMGs the "cream of the crop" because the ones who make it through are "highly desirable and motivated."

The study, if supported by other research, could have important public policy implications. One is that the that the public should have more confidence that the care provided by non-citizen IMGs (in general) is at least as good as U.S. citizens trained here, at a time when IMGs are likely to remain a critical component of a primary care workforce in shortage.

The idea that the U.S. is depending on the "cream of the crop" of non-citizen IMGs though, will add to concerns about a "brain drain" from less developed nations that have an even greater need for well-trained physicians. This concern was examined by the American College of Physicians in a 2008 policy monograph, which "cautions that the nation should not rely on IMGs alone to solve the shortage of physicians in the United States and that balance must be achieved between respecting the freedom of IMGs to migrate and fulfilling the needs of both home and host countries."

The study also speaks to the need for fundamental changes in payment and delivery models to once again attract the "best and the brightest" to internal medicine.

Today's questions: What is your reaction to the finding that non-citizens trained abroad do better than U.S. citizen IMGs or U.S. trained physicians? That board certification is positively associated with better outcomes, while years of practice since training are associated with poorer outcomes? What should policy-makers do with this information?


Harrison said...

I'm not sure that I would jump to the conclusion that any physician group 'performed' better than any other physician group on the basis of an observational study.
There is too much potential for confounding factors to draw such a conclusion.

Hopefully within the observations there is room to analyze just what decisions and what actions lead to better outcomes.
Are some doctors more likely to give Beta blockers or antiplatelet agents or cholesterol lowering agents?
Does more aggressive diuresis improve outcomes?
Do some doctors push for earlier interventions?

If we can clearly define what decisions and actions lead to better outcomes, and if it is clear that these can account for the observations --- then we can craft interventions for policy makers.

I don't think policy makers can or should do anything with the knowledge that non citizen foreign medical grads perform better. It is not wise from the perspective of world health to create further incentives to bring more of these physicians here.

I think we should aspire to train the world's best and brightest, and not simply collect them all within our own borders as hoarders of resources.


Steve Lucas said...

In my very limited experience foreign trained doctors are not exposed to the technology early in their training that is common in the US. The result is a more thorough history and hands on physical.

Again, admitting my limited experience, I have found US trained doctors to believe in technology and tests. In one personal experience a doctor made a long derogatory string of comments without looking up from the file. When I challenged him he looked up and tapping the file said the numbers do not lie.

There is a lead lag in medication and results that I feel foreign doctors may be more in tune with due to training. Doctors may need to step back from being technicians, being very good at reviewing test results, and look at their patients.

The only problem here is this takes time and currently doctors are not paid to take time with their patients.

Harrison is correct:

“I think we should aspire to train the world's best and brightest and not simply collect them all within our own borders as hoarders of resources.”

Steve Lucas

Norma said...

I think the end result depends on what you put into it. I attend UMHS St. Kitts, one of the foreign medical schools in the Caribbean. I have been well prepared and I work hard, so I have no doubt of my future success, or that the outcomes will be good.