Comparison of Surgical Residency Applicants from U'S' Medical Schools with U'S'Born and ForeignBorn

1
Comparison of Surgical Residency Applicants from
U.S. Medical Schools with U.S.-Born and
Foreign-Born International Medical School
Graduates

• Paul J. Schenarts, MD, Katie M. Love, MD,
• Steven C. Agle, MD, MPH, Carl E. Haisch, MD
• Division of Surgical Education
• Department of Surgery
• East Carolina University

2
Introduction

• Impending physician shortage
• Evolving crisis in access to emergency surgical
  care and aging population
• One solution increase number of international
  medical graduates (IMG)

3
Introduction

• International medical graduates contributions
• More frequently provide care to underserved and
  rural populations1
• Contribute to surgical research
• 21 of principal investigators of NIH research
  projects2
• Account for 19 of U.S. medical school faculty2
• Enter academic surgery at rates comparable to US
  graduates3
• 1.Howard et al, 2006
• 2. Alexander et al, 2007
• 3. Arannha, 1998

4
Problem

• The perception of the quality of IMGs
  educational preparation and performance is
  variable
• Negatives
• Discrimination by program directors1
• Diminished reputation
• Cultural and communication issues
• Higher failure rates on the Board Exam2
• 1,935 different medical schools
• Positives
• Several programs actively seek IMGs
• 1. Moore Rhondenbaugh, 2002
• 2. Norcini, et al, 2006

5
Purpose

• Compare applicant characteristics of US medical
  school graduates with US-born and foreign-born
  international medical graduates.

6
Methods

• IRB and GME approval
• Retrospective analysis
• All 2007 ERAS applicants to our general surgery
  residency
• Definition of US graduates
• Allopathic and osteopathic medical schools
• Foreign-born US graduates
• Graduates from outside the US, were considered
  IMGs
• Assignment to US-born or foreign-born IMG groups
  was based on self reported country of birth

7
Methods

• Data points
• Demographic data
• - Age - Visa status
• - Gender - Citizenship
• - Couples match - Current residence
• USMLE performance
• Number of scholarly works (presentations,
  publications)
• Attainment of advanced degrees
• Employment history since medical school
  graduation

8
Methods

• Analysis T-test and Chi square

9
Results Demographics

• U.S. Graduates U.S.-Born
  IMG Foreign-Born IMG
• Applicants 166
  85 321
• Age (Years) 28.9 ? 3.2 29.9 ? 3.5
  33.0 ? 6.6
• Male Gender 70 80
  86
• U.S. Citizenship 97 100
  15
• Living in the U.S. 100 100
  79
• Couples Match 3.6 1.2
  1.9
• Data presented as mean ? standard deviation or
  percent.
• Statistical comparisons are with U.S. graduates
  only. plt0.05, plt0.01, plt 0.0001

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Results Visa types for Foreign-Born IMGs

• Permanent Resident 28
• B-1 17
• U.S. Citizen 15
• B-2 10
• J-1 9
• F-1 7
• Other 5
• H-1B 4
• H-4 2
• EAD 1

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Results Medical School Location

• U.S. Graduates U.S.-Born IMG
  Foreign-Born IMG United States (100) Caribbean
  (70) South Asia (29)
• South Asia (9) Middle East (16)
• Central America (6) Caribbean (9)
• Middle East (5) China (8)
• Eastern Europe (3) Central America (7)
• South America (3) Eastern Europe (7)
• South Pacific (2) South
  America (5)
• Africa (1) Africa (4)
• United Kingdom (1) Central Asia (3)
• Russia (3)
• United Kingdom (2)
• Western Europe (2)
• Southeast Asia (2)
• Mediterranean (1)
• Northern Europe (1)
• South Pacific (1)

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Results USMLE Performance

• U.S. Graduate U.S.-Born IMG
  Foreign-Born IMG
• USMLE step 1 206 ? 20 200 ? 26 202 ?
  28
• Multiple attempts 9 20
  24
• USMLE step 2 213 ? 23 201 ? 29 203
  ? 31
• Multiple attempts 4 22
  19
• Data presented as mean ? standard deviation or
  percent.
• Statistical comparisons are with U.S. graduates
  only. plt0.05, plt0.01, plt 0.0001

13
Results Pre-application Experience

• U.S. Graduates U.S.-Born
  IMG Foreign-Born IMG
• Yrs since graduation 0.3 ? 0.7 1.5 ?
  1.9 7.7 ? 6.8
• Advanced degree 11
  13 19
• (Masters / PhD) (84 / 6) (91 / 9)
  (77 / 23)
• Scholarly works 1.7 ? 3.0 0.9 ?
  2.0 3.9 ? 8.4
• Jobs since graduation 0.3 ? 0.5 2.2
  ? 2.2 5.1 ? 3.9
• Data presented as mean ? standard deviation or
  percent.
• Statistical comparisons are with U.S. graduates
  only. plt0.05, plt0.01, plt 0.0001

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Results Most Common Jobs Since Graduation

• U.S. Graduates U.S.-Born IMG
  Foreign-Born IMG
• 18 Prelim Surgery 15 Research
  45 International Surg
• 2 Research 13 Prelim Surgery 44 Research
• 2 Other medicine 13 Observership 40 Other
  medicine
• 38 Observership
• 
  15 Prelim
  Surgery
• 13 Other medicine
• 12 Tech / assistant

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Discussion US-Born IMGs compared to US graduates

• Positive attributes
• Slightly older and hold more advanced degrees
• Research experience
• Clinical experience in prelim surgery or medicine
• Similar USMLE Step 1 scores
• Negative attributes
• Required multiple attempts to pass Step 1 and 2
• Significantly lower Step 2 scores
• Fewer scholarly works

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Discussion Foreign-Born IMGs compared to
US graduates

• Positive Attributes
• Hold more advanced degrees, particularly more
  PhDs
• Similar USMLE Step 1 scores
• More scholarly activity
• Greater research experience
• Significantly more clinical experience in
  international surgery or other medical fields

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Discussion Foreign-Born IMGs compared to
US graduates

• Negative attributes
• Older
• Significant time between graduation and
  application
• Lower USMLE Step 2 scores
• Required multiple attempts to pass Step 1 and 2

18
Discussion

• While most IMGs are living in the U.S., their
  medical schools are often located in areas of the
  greatest health care need
• Draining these areas of the best and brightest to
  meet U.S. needs may have ethical, social and
  political repercussions

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Discussion Limitations

• Retrospective
• Self-reported data
• Moderate size, single institution
• Rural location
• Did not determine which factors predict success

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Conclusions

• IMGs offer many attributes program directors and
  selection committees favor
• Older applicants, who graduated several years
  ago, and have trouble passing standardized tests
  may have a difficult time
• IMGs may help solve the shortage of physicians,
  however, residency programs will need to address
  communication, cultural differences, and test
  taking skills

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