International medical graduate

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An international medical graduate (IMG), earlier known as a foreign medical graduate (FMG), is a physician who has graduated from a medical school outside of the country where he or she intends to practice. The term non-local medical graduate may be similarly used in countries with distinct licensing regions within them. [1] [2] Generally, the medical school of graduation is one listed in the World Directory of Medical Schools (WDOM) as accredited by the Foundation for Advancement of International Medical Education and Research or the World Health Organization.

Contents

Medical schools around the world vary in education standards, curricula, and evaluation methods. Many countries have their own certification program, equivalent to the ECFMG in the United States. The purpose of ECFMG Certification is to assess the readiness of international medical graduates to enter clinical specialty training programs as resident physicians and fellowship programs in the United States.[ citation needed ]

License requirements by country

The requirements to obtain a license to practice varies by country and often by state, province, or territory.

Australia

IMGs (or Overseas Trained Doctors) who wish to be licensed in Australia must apply to the Australian Medical Council (AMC) to arrange an appropriate assessment pathway. [3] The standard pathway involves an IMG sitting a series of assessments, including an AMC MCQ Exam and an AMC clinical exam. [4] The AMC MCQ Exam consists of 150 MCQs organized through computer adaptive scoring.

For AMC clinical exam, a candidate is required to pass 12 out of 16 cases: including one compulsory case in both gynecology and pediatrics.

IMGs who have passed the necessary exams and obtained AMC certification can then apply to Australian specialty training positions. [5]

Australia is in the process of establishing a national registration process for all the doctors under theMedical Board of Australia.

In 2010 the Minister for Health and Ageing (Australia) launched an Inquiry process into registration and accreditation processes for international medical graduates which reported in 2012. [6]

Canada

In Canada, international medical graduates include all graduates from outside Canada. For IMGs to be eligible for full licensure in every Canadian province and territory, they must hold: [7]

The candidate must also:

However, some provinces may have alternate paths to licensure, e.g. British Columbia. [9] Alberta province, with six other provinces across Canada, has a program called Practice Ready Assessment (PRA) which enables eligible IMGs to start practice under supervision and leading to their independence where they need to fulfill certain requirements.

IMGs in Canada have a harder time getting into residency programs compared to Canadian graduates—only ten percent of IMG applicants get a position. [10]

Several organizations have put pressure on the government such as the Association For Access to Health Care Services, Alberta International Medical Graduates Association, and Association of International Physicians and Surgeons of Ontario.[ citation needed ] However, other organizations deny there is a physician shortage that requires Canada to import more physicians. [11]

United States

Applicants in the Matching Program, 2021.jpg
MatchedNRMP2021.png

In the United States, an international medical graduate (IMG) is a graduate from a medical school located outside the United States and Canada. Graduates of Canadian M.D. programs are not considered IMGs in the United States. [12] [13] IMGs may be either United States citizens or non-citizens who were educated in a school outside U.S. or Canada. [13]

Process

The main process for IMGs who wish to be licensed as physicians in the United States requires them to complete a U.S. residency hospital program. The general method to apply for residency programs is through the National Resident Matching Program (abbreviated NRMP, also called "the Match"). To participate in the NRMP match, an IMG is required to be ECFMG verified. IMGs who have not met the examination requirements for ECFMG Certification by the Rank Order List deadline *usually in February" cannot participate in the Match. [14] [15] However, for most IMGs it is advisable to have an ECFMG certification prior to participating in the match as many program directors decide not to grant interviews. [16] The purpose of ECFMG Certification is to assess whether graduates of these schools are ready to enter U.S. residency and fellowship programs that are accredited by the Accreditation Council for Graduate Medical Education (ACGME). To acquire an ECFMG certification, the main requirements are: [17]

In comparison, regular graduates from medical schools in the United States and Canada need to complete USMLE Steps 1 and 2 as well, but can participate in the NRMP while still doing their final year of medical school before acquiring their medical diplomas. [19] In effect, taking regular administrative delays into account, and with residency programs starting around July, there is a gap of at least half a year for IMGs between graduation from medical school and beginning of a residency program.

Those IMGs who have passed the necessary USMLE exams, obtained the ECFMG certification and matched to a residency position can then begin training in a residency program. [20]

USMLE exam scores are considered in the matching process for entering a residency program. [21] One study came to the result that almost half of IMGs were unsuccessful in their first attempts in the pursuit of a U.S. residency position, and three-quarters began a residency after five years. [22] It also indicated that IMGs were considerably older when they first applied for a residency position than are most U.S. medical graduates, with mean age of IMGs when the ECFMG certificate was issued being 32.4 years, with a standard deviation of 5.8 years. [22]

Applicants to residency programs in California previously needed a Postgraduate Training Authorization Letter (PTAL), colloquially called a "California Letter". PTAL was discontinued by the California Medical Board in 2020. Applicants now need a post-graduate training license similar to the one issued by other states. [23]

Concerning visa requirements, non-U.S.-citizen doctors usually enter via the J1 or the H-1B visa. The J1 requires a 2-year home residence after completion of training in the U.S. [24] The H-1B visa does not have this 2-year home residence requirement, but further requires the USMLE Step 3. And initially, a B-1 visitor visa is required for taking the USMLE Step 2 clinical skills examination and the USMLE Step 3. [25]

Indian physicians with a MBBS are qualified to take the USMLE. However, since the 2010s, the process of obtaining a license has become increasingly complicated [26] India has exported more physicians to the United States than any other foreign nation. [27]

Origin by country

The largest number of licensed International Medical Graduates comes from schools in India, the Caribbean, Pakistan and the Philippines. [28] Medical graduates from schools in the Caribbean have had the largest growth in the period between 2010 and 2018. Their numbers have increased from 22,820 to 40,689 physicians, or 78%. [28]

IMG by Country.png
Country of medical schoolPercentage of IMGsTotal number (2018)
India 23%50,173
The Caribbean 18%40,689
Pakistan 6%13,019
Philippines 6%12,744
Mexico 5%10,066
All other42%96,017

Source: 2018 FSMB Census [28]

Quality of care

One study examining quality of care by international medical graduates is noted as follows. "One-quarter of practicing physicians in the United States are graduates of international medical schools. The quality of care provided by doctors educated abroad has been the subject of ongoing concern. 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. The patient population consisted of those with congestive heart failure or acute myocardial infarction. We found no significant mortality difference when comparing all international medical graduates with all U.S. medical school graduates". [29] Data on older Medicare patients admitted to hospital in the US showed that patients treated by international graduates had lower mortality than patients cared for by US graduates. [30]

Alternative career pathways

This difficulty in attaining success to become licensed physician in their newly adopted countries, many IMGs end up taking survival jobs completely unrelated to their educational and training backgrounds. In doing so, these highly skilled immigrant health professionals have become a symbol of the deskilling of highly skilled migrants in this era of global migration. [31] Against this backdrop, alternative careers, those jobs where IMGs' health-related knowledge, skills, and experience can be used, have the prospect to facilitate better job market integration for IMGs. [32] [33]

Related Research Articles

Doctor of Medicine is a medical degree, the meaning of which varies between different jurisdictions. In the United States, and some other countries, the M.D. denotes a professional degree. This generally arose because many in 18th-century medical professions trained in Scotland, which used the M.D. degree nomenclature. In England, however, Bachelor of Medicine, Bachelor of Surgery (M.B.B.S.) was used and eventually in the 19th century became the standard in Scotland too. Thus, in the United Kingdom, Ireland and other countries, the M.D. is a research doctorate, honorary doctorate or applied clinical degree restricted to those who already hold a professional degree (Bachelor's/Master's/Doctoral) in medicine. In those countries, the equivalent professional degree to the North American, and some others' usage of M.D. is still typically titled Bachelor of Medicine, Bachelor of Surgery.

A Bachelor of Medicine, Bachelor of Surgery is an undergraduate medical degree granted by medical schools in countries that adhere to the United Kingdom's higher education tradition. Despite the historical distinction in nomenclature, these degrees are typically combined and conferred together. This degree can also be awarded at graduate-level medical institutions. The typical duration for completion is five to six years.

The United States Medical Licensing Examination (USMLE) is a three-step examination program for medical licensure in the United States sponsored by the Federation of State Medical Boards (FSMB) and the National Board of Medical Examiners (NBME). Physicians with a Doctor of Medicine (MD) degree are required to pass the USMLE for medical licensure. However, those with a Doctor of Osteopathic Medicine degree (DO) are required to take the COMLEX-USA (COMLEX) exams.

<span class="mw-page-title-main">Residency (medicine)</span> Postgraduate medical training

Residency or postgraduate training is a stage of graduate medical education. It refers to a qualified physician, veterinarian, dentist, podiatrist (DPM) or pharmacist (PharmD) who practices medicine, veterinary medicine, dentistry, podiatry, or clinical pharmacy, respectively, usually in a hospital or clinic, under the direct or indirect supervision of a senior medical clinician registered in that specialty such as an attending physician or consultant. In many jurisdictions, successful completion of such training is a requirement in order to obtain an unrestricted license to practice medicine, and in particular a license to practice a chosen specialty. In the meantime, they practice "on" the license of their supervising physician. An individual engaged in such training may be referred to as a resident, registrar or trainee depending on the jurisdiction. Residency training may be followed by fellowship or sub-specialty training.

According to the US Department of Education, the Educational Commission for Foreign Medical Graduates is "the authorized credential evaluation and guidance agency for non-U.S. physicians and graduates of non-U.S. medical schools who seek to practice in the United States or apply for a U.S. medical residency program. It provides comprehensive information and resources on licensure, the U.S. Medical Licensure Examination (USMLE), residencies, and recognition."

Step 2 Clinical Skills of the United States Medical Licensing Examination (USMLE) was an exam administered to medical students/graduates who wish to become licensed physicians in the U.S. It is similar to the COMLEX-USA Level 2-PE exam, taken by osteopathic medical students/graduates who seek licensure as physicians in the U.S. For US medical students, the exam fee is $1,300. For medical students at non-US medical schools, the tests cost is higher—currently $1,535. These fees do not include costs associated with travel and lodging to take the test. Historically, US students have taken Step 2 CS late in their senior year, prior to graduation. However, now that more residency programs require students to record a passing score, many US medical schools recommend students take Step 2 CS in the fall of their senior year.

The United States Medical Licensing Examination (USMLE) Step 1 is a standardized test that assesses a medical student's knowledge of basic science concepts and their application to clinical medicine. The exam is one of three components required for medical licensure in the United States and is typically taken by students after their second year of medical school.

The USMLE-Step 2-CK is the nine-hour-long multiple-choice portion of the second part of the United States Medical Licensure Examination. It assesses clinical knowledge through a traditional, multiple-choice examination. In contrast to the USMLE Step 1, the focus is much more on clinical application of medical knowledge. It assesses the ability to apply medical knowledge, skills, and understanding of clinical science essential for the provision of patient care under supervision. The USMLE Step 2 is generally taken during the 4th year of medical school by U.S. medical students.

<span class="mw-page-title-main">Medical University of the Americas – Nevis</span>

Medical University of the Americas (MUA) is a private for-profit offshore medical school in Charlestown, Nevis. It is owned by R3 Education, Inc. which also owns St. Matthew's University and Saba University School of Medicine MUA confers upon its graduates the Doctor of Medicine (MD) degree.

Most physicians in the United States hold either the Doctor of Medicine degree (MD) or the Doctor of Osteopathic Medicine degree (DO). Institutions awarding the MD are accredited by the Liaison Committee on Medical Education (LCME). Institutions awarding the DO are accredited by the Commission on Osteopathic College Accreditation (COCA). The World Directory of Medical Schools lists both LCME accredited MD programs and COCA accredited DO programs as US medical schools. Foreign-trained osteopaths do not hold DO degrees and are not recognized as physicians in the United States or in other jurisdictions.

The American Medical Association (AMA) Physician Masterfile includes current and historical data on all physicians, including AMA members and nonmembers, and graduates of foreign medical schools who reside in the United States and who have met the educational and credentialing requirements necessary for recognition as physicians. A Masterfile record is created and ME number assigned when entering medical school or through the ECFMG. For medical students, there are two primary methods to create the initial record - the Student Outreach Program and the annual freshman matriculation file received from the Association of American Medical Colleges (AAMC).

Doctor of Osteopathic Medicine is a medical degree conferred by the 38 osteopathic medical schools in the United States. DO and Doctor of Medicine (MD) degrees are equivalent: a DO graduate may become licensed as a physician or surgeon and thus have full medical and surgical practicing rights in all 50 US states. As of 2021, there were 168,701 osteopathic physicians and medical students in DO programs across the United States. Osteopathic medicine emerged historically from osteopathy, but has become a distinct profession.

The American University of Integrative Sciences (AUIS), is a private for-profit offshore medical school with a single campus located in Barbados. Founded in 1999, it was formerly known as the University of Sint Eustatius School of Medicine (USESOM). For a period, the school was based in Sint Maarten, where it was taken over by IEMR LLC, a US-based company. Since October 2017, AUIS has operated in Barbados, and it is currently a candidate for accreditation by the Caribbean Accreditation Authority for Education in Medicine and other Health Professions (CAAM-HP).

<span class="mw-page-title-main">UCLA IMG Program</span>

The UCLA International Medical Graduate (IMG) Program is a non-profit educational program for Hispanic International Medical Graduates who are residing in the US legally. Housed in the Dept of Family Medicine of the David Geffen School of Medicine at UCLA in Los Angeles, California the IMG Program was created to train immigrant physicians who could address the linguistic and cultural barriers to care faced by California's largely underserved Hispanic population.

Step 3 is the final exam in the USMLE series of examinations. It is part of the licensing requirements for Doctors of Medicine (M.D.), including international medical graduates aiming to practice medicine in the United States. Generally, it is a pre-requisite of the majority of the state licensing boards.

The National Board of Medical Examiners (NBME), founded in 1915, is a United States non-profit which develops and manages assessments of health care professionals. Known for its role in developing the United States Medical Licensing Examination (USMLE) in partnership with the Federation of State Medical Boards (FSMB), USMLE examinations for medical students and residents are used by medical licensing authorities in the U.S. to help determine qualifications to grant and recognize medical licenses. NBME also creates assessments and materials that are used by medical students, medical educators, practicing physicians, and for state testing of physicians already holding licenses.

The Caribbean Accreditation Authority for Education in Medicine and other Health Professions (CAAM-HP) is an accrediting body for the education programmes and schools of medicine, dentistry, veterinary medicine, nursing and other health professions in the 15 member nations of the Caribbean Community (CARICOM). CAAM-HP was established in 2003 and is headquartered in Kingston, Jamaica.

<span class="mw-page-title-main">Avalon University School of Medicine</span> Medical school in Willemstad, Curacao

Avalon University School of Medicine (AUSOM) is a private medical school located in Willemstad, Curaçao, in the Caribbean. AUSOM confers upon its graduates the Doctor of Medicine (MD) degree. Administrative offices for the university are located in Youngstown, Ohio.

An offshore medical school is a medical school that caters "primarily to foreign students, wishing to practice medicine in the US and Canada" according to the World Bank, compared to local schools that focus on their home nation. Such schools are chiefly located in the Caribbean basin, but also includes schools in other locations, such as Mexico and Australia, which run programs that target American students.

<span class="mw-page-title-main">Oceania University of Medicine</span> Independent Samoa-based medical school

Oceania University of Medicine (OUM) is an Independent Samoa-based medical school established in 2002 and operated through a public-private partnership between the Government of Samoa and e-Medical Education, LLC, a Florida-based medical education management company. Its hybrid curriculum of distance-learning preclinicals and face-to-face clinical rotations enrolls 340 students, as of August 2023, and 185 graduates are currently in residency/internship training or practicing medicine in numerous global locations, primarily Australia, Canada, New Zealand, Samoa, and the US.

References

  1. ↑ "Recruiting Non-locally trained Doctors under Limited Registration Scheme in HA" (PDF). Hospital Authority of Hong Kong. Hospital Authority. Retrieved 22 November 2019.
  2. ↑ "CUHK medical students seek Shenzhen vows". The Standard. The Standard Newspaper Publishing Ltd. Retrieved 22 November 2019.
  3. ↑ "IMG guides: Applying to the Australian Medical Council". Australian Medical Council. 27 February 2012. Archived from the original on 8 July 2014. Retrieved 7 June 2014.
  4. ↑ "Assessments & examinations: Standard pathway". Australian Medical Council. 27 February 2012. Archived from the original on 27 June 2014. Retrieved 7 June 2014.
  5. ↑ Preliminary information and application form for the AMC Examination Australian Medical Council
  6. ↑ "Inquiry into Registration Processes and Support for Overseas Trained Doctors". Parliament of Australia. Retrieved 2 June 2014.
  7. ↑ "StackPath".
  8. ↑ "StackPath".
  9. ↑ "International Medical Graduates (IMGs) | College of Physicians and Surgeons of British Columbia".
  10. ↑ readersdigest.ca - Why Is Canada Shutting Out Doctors?: "In 2003, 625 international graduates competed. Only 67—about ten percent—found a position"
  11. ↑ "What doctor shortage? – Evidence Network".
  12. ↑ "Frequently Asked Questions: 1. What Is ECFMG Certification?". 2010 ECFMG Information Booklet. Educational Commission for Foreign Medical Graduates. Retrieved 2010-04-16. Medical schools outside the United States and Canada vary in their educational standards and curricula.
  13. 1 2 "Glossary of Terms" (PDF). Accreditation Council for Graduate Medical Education . 15 April 2020. Retrieved 13 May 2021.
  14. ↑ "If I have not received my ECFMG certification when ranking opens, can I still enter my rank order list?". National Resident Matching Program. Yes, you can enter a rank order list. If the NRMP receives notification from ECFMG that you have passed the required examinations (USMLE Step 1 and Step 2 CK and CS), you will be included in the Main Residency Match.
  15. ↑ "I Am An International Medical Graduate, And My Verification Status In The R3® System Says NOT VERIFIED. What Does That Mean?". NRMP.org. NRMP.
  16. ↑ "ECFMG". Society of Interventional Radiology.
  17. ↑ ecfmg.org > Medical Education Credentials Archived 2012-08-18 at the Wayback Machine Last update: September 15, 2010
  18. ↑ "Work to relaunch USMLE Step 2 CS discontinued". usmle.org. USMLE . Retrieved 17 April 2021. "...we have decided to discontinue Step 2 CS
  19. ↑ nrmp.org > U.S. Seniors > Registering with the NRMP Archived 2011-07-21 at the Wayback Machine Updated August 2010
  20. ↑ "International Medical School Students and Graduates (IMGs) in the Match: What You Need to Know" (PDF). NRMP.org. NRMP.
  21. ↑ Catherine Rampell (August 11, 2018). "Path to United States Practice Is Long Slog to Foreign Doctors". New York Times. Retrieved July 22, 2018.
  22. 1 2 Participation in U.S. Graduate Medical Education by Graduates of International Medical Schools By Jolly, Paul PhD; Boulet, John PhD; Garrison, Gwen PhD; Signer, Mona M. MPH. Posted: 05/23/2011; Academic Medicine. 2011;86(5):559-564.
  23. ↑ "Frequently Asked Questions - Postgraduate Training License". mbc.ca.gov. Medical Board of California . Retrieved 17 April 2021. Will international medical school graduates require a Postgraduate Training Authorization Letter (PTAL) to participate in an ACGME-accredited postgraduate training program in California?
  24. ↑ "Immigration Information for International Medical Graduates". American Medical Association. Retrieved July 22, 2018.
  25. ↑ "The 10 Biggest Immigration Mistakes Physicians Make". www.seak.com. 2014-10-14. Retrieved July 22, 2018.
  26. ↑ Rampell, Catherine (2013-08-11). "Path to United States Practice is Long Slog to Foreign Doctors". The New York Times.
  27. ↑ "India's Doctors Returning Home". NPR.org.
  28. 1 2 3 "FSMB Census of Licensed Physicians in the United States, 2018" (PDF). FSMB . Retrieved 17 April 2021. ...The largest number of licensed IMGs have graduated from...
  29. ↑ Norcini, John J; Boulet, John R; Dauphinee, W Dale; Opalek, Amy; Krantz, Ian D; Anderson, Suzanne T (August 2010). "Evaluating the quality of care provided by graduates of international medical schools". Health Affairs. 29 (8): 1461–8. doi:10.1377/hlthaff.2009.0222. PMID   20679648.
  30. ↑ Tsugawa, Yusuke; Jena, Anupam B.; Orav, E John; Jha, Ashish K. (3 February 2017). "Quality of care delivered by general internists in US hospitals who graduated from foreign versus US medical schools: observational study". BMJ. 356: j273. doi:10.1136/bmj.j273. PMC   5415101 . PMID   28153977.
  31. ↑ Turin, Tanvir C.; Chowdhury, Nashit; Lake, Deidre (2022-03-16). "Lost in Transition: The Need for a Strategic Approach to Facilitate Job Market Integration of Internationally Educated Physicians through Alternative Careers". International Journal of Environmental Research and Public Health. 19 (6): 3503. doi: 10.3390/ijerph19063503 . ISSN   1660-4601. PMC   8954027 . PMID   35329190.
  32. ↑ Turin, Tanvir C.; Chowdhury, Nashit; Ekpekurede, Mark; Lake, Deidre; Lasker, Mohammad Ali Ashraf; O’Brien, Mary; Goopy, Suzanne (December 2021). "Professional integration of immigrant medical professionals through alternative career pathways: an Internet scan to synthesize the current landscape". Human Resources for Health. 19 (1): 51. doi: 10.1186/s12960-021-00599-8 . ISSN   1478-4491. PMC   8052743 . PMID   33865402.
  33. ↑ Turin, Tanvir C.; Chowdhury, Nashit; Ekpekurede, Mark; Lake, Deidre; Lasker, Mohammad; O'Brien, Mary; Goopy, Suzanne (2021-04-09). "Alternative career pathways for international medical graduates towards job market integration: a literature review". International Journal of Medical Education. 12: 45–63. doi:10.5116/ijme.606a.e83d. ISSN   2042-6372. PMC   8415394 . PMID   33839694.
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