Quality of medical care by foreign doctors?

A new study has summarized the outcome of cases of heart attack and congestive heart failure when treated by American or foreign physicians.

The patients of foreign-born international graduates had the lowest death rate, 5 percent, and the patients of American doctors trained overseas had the highest death rate, 5.8 percent. Patients of the American born-and-trained doctors fell in the middle, with 5.5 percent.

However, when non-US born foreign medical graduates (FMGs) are lumped together with US-born FMGs, there was no difference in outcome when compared to American medical graduates (AMGs).

20% of all FMGs are Americans who had their education in international medical schools, often in the Caribbean. Most foreign-born international graduates come from India and Pakistan, who have completed medical school in their native country. In addition, these foreign-born FMGs often have had additional medical training in these locations abroad, before entering residency training with fresh AMGs.

The authors think that the worse performance of the US-born FMGs as compared to the other two groups could be due to two reasons. For one, Americans choosing to study abroad may have failed to get admission in a US medical school because of their grades, implying that they may be less capable to start with. In addition, it is possible that many foreign schools they attend may have lower standards of education and training.

All FMGs, whether or not born in the US, must take the same series of rigorous examinations given to AMGs, and also complete the same residencies and appear in the same board qualification examinations that AMGs do. Residencies done in non-US hospitals (except for Canada) are not recognized.

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The first author of this study is John J. Norcini, president of the Foundation for Advancement of International Medical Education and Research, in Philadelphia. The study is being published in the August issue of the Journal Health Affairs. Here’s the abstract:

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.

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I hope that more studies are conducted on this topic, since it has huge implications. There is an ongoing shortage of doctors in the US, especially in the fields where reimbursement is poor, like Family Practice, Internal Medicine or Pediatrics. This vacuum has traditionally been filled with FMGs who are willing to train and practice in these specialities.

The addition of over 10% of the population (32 million) to those eligible to receive healthcare by the newly passed Healthcare Reform will aggravate this shortage. There are efforts to increase class sizes and open new medical schools in the US, but the number of residency slots remain the same. This raises a few issues:

1. As the authors caution, schools should not lower their admission standards and accept American applicants who would have had gone to study abroad because of their grades. If they do, medical schools may be churning out many less competent doctors.
2. Since there will be a gradual increase in the number of AMGs, without a concurrent increase in residency positions, they will have to squeeze out FMGs. If these ‘displacers’ are doctors who would have otherwise been American FMGs, there will be a lowering of the quality of healthcare in the US.
3. Ultimately, the number of doctors available every year will depend on the number of medical graduates completing their residency programs, whether they are AMGs or FMGs. So there will be no net gain in the number of practicing physicians.

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These matters need to be addressed. The number of post-graduate training positions have to be increased to meet the new influx of healthcare consumers, and the high standards of medical school admissions have to be preserved to maintain the quality of care in the US healthcare system.