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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.

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Case Illustration 1

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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!"

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International medical graduates are filling an increasing proportion of the U.S. family medicine residency positions. The results of the 2005 NRMP indicate that 24.3% of all matched positions in family medicine were filled by the non-U.S. citizens educated internationally, marking the seventh consecutive year when more positions in family medicine were filled with non-U.S. citizen IMGs than the previous year. These changes in family medicine residencies parallel those in medicine in general. Twenty-five percent of all pediatrics and 35% of internal medicine residency positions were filled with IMGs in 2005, with the majority of these IMGs being non-U.S. citizens (69.8% and 78.6%, respectively). The top 10 countries for medical school training include: India, the Philippines, Mexico, Pakistan, Dominican Republic, Russia and other former eastern block countries, Grenada, Egypt, Italy, and South Korea. One in four physicians in the United States is an IMG; that is, 185,234 physicians coming from 127 different countries. IMGs are well represented in primary care professions (family medicine, internal medicine, pediatrics), and they provide a disproportionate share of health care in medically underserved areas.

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With the anticipated physician shortage and distribution of the U.S. physician workforce away from primary care, the increase in IMGs entering primary care specialties is likely to continue. Previous assumptions about the prior training of first-year residents no longer apply to a large percentage of ...

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