International medical graduate

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.

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

Main article: Overseas trained doctors in 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 with the exception of graduates from United States LCME accredited medical schools ^[7][8]

For IMGs to be eligible for full licensure in every Canadian province and territory, they must hold:^[9]

• A medical degree from a school listed in the World Directory of Medical Schools with a Canada Sponsor Note ; OR
• A Doctor of Osteopathic Medicine degree from a U.S. school accredited by the AACOM; OR

The candidate must also:

• Be a Licentiate of the Medical Council of Canada (LMCC), which requires passing the MCCQE Part I and Part II
• Complete postgraduate training program in allopathic medicine and been evaluated by a recognized authority. For entering a residency program, the candidate must first pass the National Assessment Collaboration Examination^[10]
• Be certified by the College of Family Physicians of Canada, the Royal College of Physicians and Surgeons of Canada, or the Collège des médecins du Québec.

However, some provinces may have alternate paths to licensure, e.g. British Columbia.^[11]

IMGs in Canada have a harder time getting into residency programs compared to Canadian graduates—only ten percent of IMG applicants get a position.^[12]

Several organizations have put pressure on the government such as the Association For Access to Health Care Services, 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.^[13]

United States

 

 

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.^[14][15] IMGs may be either United States citizens or non-citizens who were educated in a school outside U.S. or Canada.^[15]

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.^[16][17] 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.^[18] 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:^[19]

• Completion of USMLE Step 1, USMLE Step 2 Clinical Knowledge. Previous to 2021 the USMLE Step 2 Clinical Skills was also required but has now been discontinued.^[20]
• A medical diploma of medical education taken at an institution registered in the World Directory of Medical Schools (WDOM)

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.^[21] 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.^[22]

USMLE exam scores are considered in the matching process for entering a residency program.^[23] 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.^[24] 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.^[24]

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.^[25]

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.^[26] 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.^[27]

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^[28] India has exported more physicians to the United States than any other foreign nation.^[29]

Origin by country

The largest number of licensed International Medical Graduates comes from schools in India, the Caribbean, Pakistan and the Philippines.^[30] 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%.^[30]

 

Country of medical school	Percentage of IMGs	Total number (2018)
India	23%	50,173
The Caribbean	18%	40,689
Pakistan	6%	13,019
Philippines	6%	12,744
Mexico	5%	10,066
All other	42%	96,017

Source: 2018 FSMB Census^[30]

Further information: Educational Commission for Foreign Medical Graduates

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".^[31] 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.^[32]

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. . Australian Medical Council. 27 February 2012. Archived from the original on 8 July 2014. Retrieved 7 June 2014.
4. . Australian Medical Council. 27 February 2012. Archived from the original on 27 June 2014. Retrieved 7 June 2014.
5. Australian Medical Council
6. "Inquiry into Registration Processes and Support for Overseas Trained Doctors". Parliament of Australia. Retrieved 2 June 2014.
7. . Medical Council of Canada. Archived from the original on 2010-04-17. Retrieved 2010-04-16.
8. "Ontario".
9. "StackPath".
10. "StackPath".
11. "International Medical Graduates (IMGs) | College of Physicians and Surgeons of British Columbia".
12. readersdigest.ca - Why Is Canada Shutting Out Doctors?: "In 2003, 625 international graduates competed. Only 67—about ten percent—found a position"
13. "What doctor shortage? – Evidence Network".
14. "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.
15. "Glossary of Terms" (PDF). Accreditation Council for Graduate Medical Education. 15 April 2020. Retrieved 13 May 2021.
16. "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.
17. "I Am An International Medical Graduate, And My Verification Status In The R3® System Says NOT VERIFIED. What Does That Mean?". NRMP.org. NRMP.
18. "ECFMG". Society of Interventional Radiology.
19. ecfmg.org > Medical Education Credentials Last update: September 15, 2010
20. "Work to relaunch USMLE Step 2 CS discontinued". usmle.org. USMLE. Retrieved 17 April 2021. "...we have decided to discontinue Step 2 CS
21. nrmp.org > U.S. Seniors > Registering with the NRMP 2011-07-21 at the Wayback Machine Updated August 2010
22. "International Medical School Students and Graduates (IMGs) in the Match: What You Need to Know" (PDF). NRMP.org. NRMP.
23. Catherine Rampell (August 11, 2018). "Path to United States Practice Is Long Slog to Foreign Doctors". New York Times. Retrieved July 22, 2018.
24. 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.
25. "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?
26. "Immigration Information for International Medical Graduates". American Medical Association. Retrieved July 22, 2018.
27. "The 10 Biggest Immigration Mistakes Physicians Make". www.seak.com. 2014-10-14. Retrieved July 22, 2018.
28. Rampell, Catherine (2013-08-11). "Path to United States Practice is Long Slog to Foreign Doctors". The New York Times.
29. "India's Doctors Returning Home". NPR.org.
30. "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...
31. 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 (Millwood). 29 (8): 1461–8. doi:10.1377/hlthaff.2009.0222. PMID 20679648.
32. 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.

External links

• Educational Commission for Medical Graduates
• United States Medical Licensing Exam (USMLE)
• National Resident Matching Program