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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.


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 infamily 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!”


International medical graduates are filling an increasing proportion of openings in US primary care specialties. Match results from 2013 indicate that 13% of postgraduate year (PGY)1 family medicine residents were non-US citizen IMGs with comparable figures of 27% for internal medicine and 11% of pediatrics. The percentage of IMGs entering internal medicine residencies has remained fairly constant over the past several years while percentages of non-US citizen IMGs entering family medicine and pediatric residencies has declined slightly. In 2013, the top three countries for IMGs’ medical education were India, the Philippines, and Mexico. At present, about 30% of practicing physicians in primary care specialties come from outside the United States. A similar pattern exists for Canada, Britain, and Australia. For example, in Britain, one-third of all practicing physicians are IMGs. As noted above, in the United States, IMGs are well represented in primary care specialties (family medicine, internal medicine, and pediatrics) and it is estimated that they will soon represent 35% of the primary care physician workforce. International Medical Graduates currently provide a disproportionate share of health care in medically underserved areas.

As noted by geographic data, a high proportion of US and Canadian noncitizen physicians come from less developed countries that are poor in resources. In addition to the ...

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