Contribution of Caribbean-Trained Physicians to US Workforce
Purpose There is a projected shortage of primary care physicians in the United States, and providers other than U.S medical graduates may be needed to fill the gap. The authors conducted this study to quantify the contribution that Caribbean-educated physicians make to the U.S. primary care workforce
Method Using May 2011 American Medical Association Physician Masterfile and Educational Commission for Foreign Medical Graduates data, the authors identified physicians whose Masterfile records indicated that they provided direct patient care. They classified these physicians according to the type of medical school from which they graduated: graduates of Caribbean medical schools (C-IMGs), graduates of other international medical schools (non-C-IMGs), graduates of U.S. MD-granting medical schools (USMGs), and graduates of U.S. DO-granting medical schools (DOs). They then calculated the frequencies and percentages of self-designated primary care specialties for each physician classification
Results There were 684,469 physicians in direct patient care categories for whom data were available concerning medical school and self-designated specialty. About one-quarter of these physicians were graduates of international medical schools (C-IMGs: 3.0%, n = 20,333; non-C-IMGs: 20.4%, n = 139,415), and approximately three-quarters were U.S. medical school graduates (USMGs: 70.3%, n = 481,061; DOs: 6.4%, n = 43,660). Overall, C-IMGs had the highest proportion of physicians practicing in primary care specialties (56.7%) compared with non-C-IMGs (42.3%), USMGs (32.9%), and DOs (54.0%)
Conclusions More than half of Caribbean-educated physicians involved in direct patient care are practicing in primary care specialties, thereby making an important contribution to the U.S. primary care workforce.
The U.S. primary care workforce is facing numerous challenges. The federal government's recent health care reform efforts are likely to lead to greater demand for physician services, particularly primary care. The Association of American Medical Colleges estimates, however, that the nation is on track to have about 45,000 fewer primary care physicians than it will need by 2020. Many Americans live in areas where the availability of primary care services is already limited, and the needs of newly insured patients will exacerbate existing access problems. At the same time, trends in U.S. demographics—including population growth, aging, and an increase in lifestyle diseases—are expected to intensify the need for primary care physicians.
Compounding the crisis, fewer graduates of U.S. MD-granting medical schools (USMGs) are choosing primary care specialties. Among a sample of 1997–2006 USMGs, specialty choices decreased over time in the fields of general medicine, family medicine, general pediatrics, and obstetrics–gynecology. If these trends continue, recent increases in the number of U.S. MD-granting medical schools and in class sizes are unlikely to result in appreciably higher numbers of primary care physicians; rather, they may contribute to worsening health care costs and access problems.
Numerous solutions to these challenges have been proposed, such as providing training in outpatient settings and loan forgiveness programs. However, because of philosophical disagreements, the complexity of legislative change, and cost issues, no clear and simple strategy has emerged that will ensure a sufficient workforce of primary care physicians now and in the future.
Although the majority of physicians in residency training and practice in the United States are USMGs, approximately 25% are graduates of international medical schools (IMGs). Studies have shown IMGs to be more likely than USMGs to specialize in primary care disciplines and to practice in rural areas. In 2005–2006, 24.6% of all visits to office-based physicians were to IMGs.
The source countries of IMGs have been changing over time. The number of graduates of Caribbean medical schools (C-IMGs) certified by the Educational Commission for Foreign Medical Graduates (ECFMG)* has increased each year since 2000. In 2006, only 1,860 (17.2%) of the 10,818 ECFMG-certified IMGs graduated from Caribbean medical schools; by 2011, 2,936 (30.0%) of the 9,791 physicians certified graduated from institutions located in the Caribbean. The number of medical schools in the Caribbean region has also grown since 2000: Of the 63 open Caribbean medical schools listed in the International Medical Education Directory in 2012, just 38 were established before 2000, whereas 12 were established during 2000–2005 and 13 have opened since 2006. Many of these schools recruit, almost exclusively, U.S. citizens and international students who intend to pursue residency training and licensure in the United States.
Concerns have been raised regarding the quality of the education provided at Caribbean institutions in light of the rising number of C-IMGs seeking residency and practice opportunities in the United States, the number of recently established schools in the region, and the lack of a uniform system of quality assurance oversight for the region's medical schools. Recent studies have documented that, on average, C-IMGs seeking to enter graduate medical education (GME) programs in the United States do not perform as well on qualifying exams and other proxy measures of ability as do USMGs or graduates of international medical schools in non-Caribbean countries (non-C-IMGs). Nevertheless, many C-IMGs eventually pass the requisite examinations, achieve ECFMG certification, obtain GME positions, and go on to unsupervised practice in the United States.
Although medical education in the Caribbean region is often viewed as uniform, there is evidence of wide variation in medical schools' selection processes, clinical training opportunities, and student performance. Whereas some schools may be small or underresourced, several are accredited by agencies that have been deemed to use criteria comparable to the standards used to accredit U.S. medical schools. In addition, there is evidence that the average performance of C-IMGs on the United States Medical Licensing Examination (USMLE) has been improving.
These physicians, whose role in patient care in the United States is often overlooked, represent a potentially valuable human resource for the delivery of primary care services. The majority of the C-IMGs certified by the ECFMG are from North America and desire practice opportunities in the United States: Of the 2,936 ECFMG certificates issued in 2011 to C-IMGs, 2,024 (69.0%) were awarded to U.S. citizens and 422 (14.0%) to Canadian citizens. Given that various parties have attempted to limit C-IMGs' training opportunities and practice settings, we believe it is important to consider this group of physicians' current and prospective workforce contributions, particularly in primary care specialties where there is great need. We therefore conducted this study to quantify C-IMGs' contribution to the U.S. primary care workforce.
Abstract and Introduction
Abstract
Purpose There is a projected shortage of primary care physicians in the United States, and providers other than U.S medical graduates may be needed to fill the gap. The authors conducted this study to quantify the contribution that Caribbean-educated physicians make to the U.S. primary care workforce
Method Using May 2011 American Medical Association Physician Masterfile and Educational Commission for Foreign Medical Graduates data, the authors identified physicians whose Masterfile records indicated that they provided direct patient care. They classified these physicians according to the type of medical school from which they graduated: graduates of Caribbean medical schools (C-IMGs), graduates of other international medical schools (non-C-IMGs), graduates of U.S. MD-granting medical schools (USMGs), and graduates of U.S. DO-granting medical schools (DOs). They then calculated the frequencies and percentages of self-designated primary care specialties for each physician classification
Results There were 684,469 physicians in direct patient care categories for whom data were available concerning medical school and self-designated specialty. About one-quarter of these physicians were graduates of international medical schools (C-IMGs: 3.0%, n = 20,333; non-C-IMGs: 20.4%, n = 139,415), and approximately three-quarters were U.S. medical school graduates (USMGs: 70.3%, n = 481,061; DOs: 6.4%, n = 43,660). Overall, C-IMGs had the highest proportion of physicians practicing in primary care specialties (56.7%) compared with non-C-IMGs (42.3%), USMGs (32.9%), and DOs (54.0%)
Conclusions More than half of Caribbean-educated physicians involved in direct patient care are practicing in primary care specialties, thereby making an important contribution to the U.S. primary care workforce.
Introduction
The U.S. primary care workforce is facing numerous challenges. The federal government's recent health care reform efforts are likely to lead to greater demand for physician services, particularly primary care. The Association of American Medical Colleges estimates, however, that the nation is on track to have about 45,000 fewer primary care physicians than it will need by 2020. Many Americans live in areas where the availability of primary care services is already limited, and the needs of newly insured patients will exacerbate existing access problems. At the same time, trends in U.S. demographics—including population growth, aging, and an increase in lifestyle diseases—are expected to intensify the need for primary care physicians.
Compounding the crisis, fewer graduates of U.S. MD-granting medical schools (USMGs) are choosing primary care specialties. Among a sample of 1997–2006 USMGs, specialty choices decreased over time in the fields of general medicine, family medicine, general pediatrics, and obstetrics–gynecology. If these trends continue, recent increases in the number of U.S. MD-granting medical schools and in class sizes are unlikely to result in appreciably higher numbers of primary care physicians; rather, they may contribute to worsening health care costs and access problems.
Numerous solutions to these challenges have been proposed, such as providing training in outpatient settings and loan forgiveness programs. However, because of philosophical disagreements, the complexity of legislative change, and cost issues, no clear and simple strategy has emerged that will ensure a sufficient workforce of primary care physicians now and in the future.
Although the majority of physicians in residency training and practice in the United States are USMGs, approximately 25% are graduates of international medical schools (IMGs). Studies have shown IMGs to be more likely than USMGs to specialize in primary care disciplines and to practice in rural areas. In 2005–2006, 24.6% of all visits to office-based physicians were to IMGs.
The source countries of IMGs have been changing over time. The number of graduates of Caribbean medical schools (C-IMGs) certified by the Educational Commission for Foreign Medical Graduates (ECFMG)* has increased each year since 2000. In 2006, only 1,860 (17.2%) of the 10,818 ECFMG-certified IMGs graduated from Caribbean medical schools; by 2011, 2,936 (30.0%) of the 9,791 physicians certified graduated from institutions located in the Caribbean. The number of medical schools in the Caribbean region has also grown since 2000: Of the 63 open Caribbean medical schools listed in the International Medical Education Directory in 2012, just 38 were established before 2000, whereas 12 were established during 2000–2005 and 13 have opened since 2006. Many of these schools recruit, almost exclusively, U.S. citizens and international students who intend to pursue residency training and licensure in the United States.
Concerns have been raised regarding the quality of the education provided at Caribbean institutions in light of the rising number of C-IMGs seeking residency and practice opportunities in the United States, the number of recently established schools in the region, and the lack of a uniform system of quality assurance oversight for the region's medical schools. Recent studies have documented that, on average, C-IMGs seeking to enter graduate medical education (GME) programs in the United States do not perform as well on qualifying exams and other proxy measures of ability as do USMGs or graduates of international medical schools in non-Caribbean countries (non-C-IMGs). Nevertheless, many C-IMGs eventually pass the requisite examinations, achieve ECFMG certification, obtain GME positions, and go on to unsupervised practice in the United States.
Although medical education in the Caribbean region is often viewed as uniform, there is evidence of wide variation in medical schools' selection processes, clinical training opportunities, and student performance. Whereas some schools may be small or underresourced, several are accredited by agencies that have been deemed to use criteria comparable to the standards used to accredit U.S. medical schools. In addition, there is evidence that the average performance of C-IMGs on the United States Medical Licensing Examination (USMLE) has been improving.
These physicians, whose role in patient care in the United States is often overlooked, represent a potentially valuable human resource for the delivery of primary care services. The majority of the C-IMGs certified by the ECFMG are from North America and desire practice opportunities in the United States: Of the 2,936 ECFMG certificates issued in 2011 to C-IMGs, 2,024 (69.0%) were awarded to U.S. citizens and 422 (14.0%) to Canadian citizens. Given that various parties have attempted to limit C-IMGs' training opportunities and practice settings, we believe it is important to consider this group of physicians' current and prospective workforce contributions, particularly in primary care specialties where there is great need. We therefore conducted this study to quantify C-IMGs' contribution to the U.S. primary care workforce.
Source...