The United States healthcare system is inundated with diversity. We host one of the greatest varieties of patient demographics, types of health professions, and countries of origin within the physician workforce. Unfortunately, medical education programs have fallen behind in many ways. The current system often fails to provide equality of educational opportunities to students from diverse international regions. ECFMG-Certified Physicians play a vital role in US healthcare and should be viewed as such.

Medical Education as a Foreign Medical Student

Getting into medical schools is a dream come true for students from any country. They will now be able to express their passions and utilize their years of education to help their communities. However, students and medical graduates from non-US countries (or study abroad) will face unique challenges when attempting to advance their academic careers in the US.

Medical students who study abroad or come from medical institutions outside of the United States are considered international medical students (IMS). Those who have graduated are often referred to as international or foreign medical graduates (IMGs/FMGs). But IMSs/IMGs are often neglected in the U.S. health education system.

Lack of adequate clinical opportunities and exposure to various clinical settings creates a deficit in many learner’s experiences. This factor should not be overlooked as a significant percentage of the healthcare workforce in the United States is made up of IMGs.

Covid Pandemic and International Medical Graduates

Starting from 2019, the COVID pandemic has affected our entire planet in ways this generation had never experienced. However, no community has been hit quite the way that medicine and medical education have. In March, hospital lockdowns began and students were recommended to refrain from clinical contact during this time.

Hospitals and healthcare facilities faced severe shifts in their patient care routines. Many saw a rapid influx of patients with respiratory illness and COVID-associated problems. There were personal protective equipment (PPE) shortages that left healthcare workers unprotected and limited students further. IMGs who sought observerships and externships were often left with little to no support.

All healthcare learners were displaced from their normal clinical schedules. However, the effect was much more restricted for international graduates. Very few clinical rotations were available to IMGs and medical programs closed their doors to non-affiliated learners. Unlike their AMG colleagues, IMGs did not have the same access to virtual learning and other alternative clinical education. This has led to an uncertain future for many trainees who are still struggling to gain more clinical exposure.

IMGs Observerships and Externships

International students have always faced a negative stigma in our health system. US citizens that study abroad and return home to practice face many challenges. Even those that do very well on their medical boards, have great communication skills, and complete postgraduate training may face certain predisposed notions about their abilities and medical training. However, the influx of medical school graduates from foreign school programs has not ceased. In fact, it seems to steadily increase each year which has led to an educational disconnect. These challenges need to be understood, met, and overcome.

Lack of Clinical Sites: The primary problem facing students, both AMG and IMG alike, is the lack of clinical opportunities. The clinical rotation sites, number of preceptors, and number of sub-specialty experiences offered are very limited. Students are often forced to accept elective externships in specialties they have no interest in pursuing simply to fill academic requirements. Others must compete with PA students and NP students for the same clinical seat.

Affordability: Determined students may look outside of their school’s limited resources and find clerkships in other locations. However, to do so is competitive. This competitiveness often limits this option to those with greater financial resources. The extra tuition, travel costs, and living expenses can add up quickly and not all learners will be able to take on the extra debt.

Scheduling: Setting up external clinical rotations takes time. A learner must search for the appropriate program, check for availability, and communicate several times with the program director. Even then, the process is usually antiquated and inefficient leading to a lot of wasted time for all involved.

Importance of IMGs In the Workforce

The importance of these medical graduates cannot be looked over. For one, IMGs often have exposure to work and systems in different healthcare designs. This can lead to observations and conceptualizations that native physicians may not see. Combined with practicing in the US, this experience can help develop a unique skill set in these physicians.

It also helps to improve the quality of health care and treatments presented to patients from different cultural backgrounds. Internationally-trained general practitioners (GPs) are nothing new in US healthcare. Patients with healthcare professionals who understand their culture and heritage are likely to be more accepting of treatment and have better patient outcomes.

In the 2020 Match, 12,074 international medical graduates applied for U.S. residentcy positions. Out of the total, 5167 graduates ( 42.7%) were US citizens. This demonstrates that a considerable percentage of successful US doctors are foreign graduates.

Statistical Overview of International Medical Graduates

Statistical data has shown excellent percentages of International medical graduates working in various clinical electives. According to Active Physicians Who Are International Medical Graduates (IMGs) by Specialty, 2019 Report, there are 938,966 active physicians, of which 232,190 are IMGs. This is approximately 1/4 of the total US physician workforce. By specialty, we can notice some points of interest.

  • 1119 out of a total of 4900 active physicians in allergy and Immunology were IMGs.
  • Out of 13093, 5388 active physicians in Critical Care Medicine had an international degree.
  • The highest percentage (51.2) was present in Geriatric Medicine, in which there were 3097 IMGs out of a total of 5974 working doctors.
  • The cardiovascular department had 22,521 physicians working, and 6,973 were qualified physicians from countries other than the United States.
  • FM had 28,569 IMGs out of 118,198 physicians (24.2%).

Although US-born healthcare workers still make up the majority in nearly all specialties, there is a significant role being played by international graduates. One of the best ways to combat the constant physician shortage concern is to better train and utilize international students.

A New System for Clinical Rotations - Crowdsourcing

The hurdles faced by international medical graduates are well more known. There have to be solutions to compensate for the difference in attention to clinical education for the international medical graduate. If the focus remains only on the American medical graduate then we will continue to have a deficiency in training options for approximately 1/4 of our physician workforce. But the solution may be much simpler than some would believe.

The quickest and most efficient manner to increase clinical training sites is by crowdsourcing. This will give a significantly increased number of students educational opportunities than are currently allowed. Crowdsourcing involves the use of additional untapped resources within the community. For clinical education, this means tapping into the nearly 80% of non-academic physicians!

Many of these physicians have an interest in teaching medical students. They are often simply lacking the administrative tools and access to resources that their academic counterparts have. However, when streamlining the process of student aquasition, scheduling, and documentation many more are willing to donate (or be compensated for) their time.

Crowdsourcing also reduces the program cost and increases affordability for the students. Increasing the supply of clinical sites means that smaller schools do not need to compete financially with more competitive larger schools for the same locations.

Benefits to Preceptors

Clinical experience (research, elective rotations, observership programs) can require a lot of documentation. This documentation can be automated and sent through SMS or e-signature formats for easy completion. No need to fax, download, sign, re-upload, and email documentation between the school and clinical site. Making it easy for the clinical instructor can increase retention and decrease stress.

Student evaluations, course expectations, completion documents, and letters of recommendation can all be completed quickly and backed up for safe keeping. The residency application process will require confirmation and copies of clerkship and observership paperwork.

Besides intrinsic motivation for education, there are many incentives to encourage more physicians to teach medical learners. Tax deductions, CME, teaching awards, and other extrinsic motivators really help compensate the physicians for their dedication and time.

An annual tax deduction can range from $1,000 to $10,000 depending on the state, and numerous medical societies offer teaching awards to boost one’s academic aspirations. Of course, if this isn’t enough, preceptors can also be compensated financially for their time and efforts!

How IMGs Can FindARotation

The development of a centralized marketplace for AMGs and IMGs makes the entire pre-residency clinical experience much easier. By having a central location that aims to bring efficiency and affordability to students, medical learners can focus on their academic needs and not waste time with complicated scheduling services.

IMGs strengthen the structural and clinical framework by providing their services to the health care system. It only makes sense that the rest of the clinical education, and society in general, return the favor. The successful deep training of IMGs can only lead to better patient outcomes and a more diverse medical institution.

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