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INTRODUCTION

This chapter will review issues involved in the training and education of international medical graduates (IMGs), including differing views of psychiatric conditions and treatment, differences in educational experiences, clinical issues involving interactions with patients and nonphysician staff, technology and documentation, psychosocial issues, and medical ethics. General suggestions are offered regarding possible modifications to residency education to address the special needs of these trainees. As in any discussion of cross-cultural differences, the tremendous variability in the backgrounds of IMGs must be acknowledged. Generalizations will always be qualified and may not reflect the experience of all IMGs.

BACKGROUND

image CASE ILLUSTRATION 1

The primarily U.S.-trained family medicine residency faculty meets one last time to review candidates before submitting their final rank order list to the National Resident Matching Program (NRMP). With few exceptions, the rank order begins with the U.S. medical graduates (USMGs) and ends with IMGs, who comprise two-thirds of the total list. Visa issues further complicate the selection process. “She is a strong applicant, but her visa status is likely to cause some administrative difficulties.” Thoughtful, sensitive discussions sort out which applicants, particularly among the IMGs, appear genuinely interested in family medicine; which applicants are more familiar with the U.S. medical system; which applicants might effectively relate to and communicate with this residency’s low-income, urban population; and which applicants might appreciate and attend to psychosocial issues in patient care. One faculty member comments, “The ranking process was more straightforward when we considered only USMGs.” Another adds, “So was residency education!” A third retorts, “Don’t forget, some of our strongest residents have been IMGs!”

Since our original research paper on the topic published in 2006, the past decade has seen a growing number of studies—primarily qualitative—focusing on the experience of international medical graduates. Recently, there has been a growing educational and evidence-based literature on the topic including systematic reviews. Many of the issues that we reported—lack of experience in the biopsychosocial model, a narrow biomedical orientation, collaborative versus hierarchical physician–patient relationship, hierarchical versus more egalitarian interaction with faculty, disclosure of medical bad news, the individualist focus on patient autonomy supported by law in the United States versus a collectivist or family-centered communication style—have been reported in studies conducted in the United States, Canada, the United Kingdom, and Germany.

GROWING NUMBER OF IMGS

International medical graduates provide a good deal of primary care in the United States; about 30% of practicing physicians in primary care specialties are IMGs. A similar pattern exists for Canada, Britain, and Australia. For example, in Britain, one-third of all practicing physicians are IMGs. The top three specialties for non-U.S. citizens who were graduates of international medical schools were internal medicine, family medicine, and pediatrics. It is estimated that IMGs will soon represent 35% of the U.S. primary care physician workforce. In Germany, IMGs comprise about 10% of the medical workforce. In the United ...

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