This study suggests that IMGs and USMGs who practise family medicine differ in important ways. Professionally, fewer IMGs are board-certified, compared to USMGs. Their practices differ from those of USMGs in terms of practice location and service of the Medicare and Medicaid populations. Significantly fewer IMGs report being satisfied overall with their medical careers than USMGs. Furthermore, subtle differences exist between the groups in regards to patient referral patterns and in their responses to several clinical vignettes. These differences, if they continue to exist, may affect important aspects of the health care system, particularly access to care and health care use and costs.
Fewer IMGs are board-certified than USMGs
The CTS survey data do not allow us to ascertain the etiology of this profound difference. Prerequisites for becoming board-certified in family medicine include unlimited licensure to practise medicine, completion of a three-year residency programme in family medicine, with the last two years being at the same location, and a passing score on the American Board of Family Practice Board Certification Exam.
Physicians surveyed in this study were practising medicine prior to the implementation of the Clinical Skills Assessment (CSA) requirement for IMGs to enter United States residency programmes. This requirement was implemented by the Educational Commission for Foreign Medical Graduates (ECFMG) in July 1998 to evaluate IMGs' clinical and communication skills . Since the implementation of the CSA, the United States Medical Licensing Exam (USMLE) Step 1 and 2 passage rates of IMGs receiving ECFMG certification have increased. We may also see increases in the percentage of board-certified IMG family physicians in the future with this new requirement.
It is uncertain how board certification and exam-passing rates correlate to quality outcomes in clinical practice. An extensive literature review performed in 1997 revealed that insufficient evidence existed to support or refute the use of board certification as a proxy for physician quality . More recent studies suggest that board certification and maintenance of certification may be linked to improved clinical outcomes . Furthermore, the public places a high value on board certification and would potentially change behaviour to ensure their physician is board-certified. The difference between IMGs' and USMGs' board certification status is important, as more emphasis is being placed on this credential. It is also important to address the proposed link between board-certification status and physician quality in future studies.
Significantly more IMG family physicians are practising in more urban areas as opposed to rural areas
Previous studies found that IMGs comprise a larger portion of the primary-care physician workforce in rural areas with physician shortages than USMGs, but these studies lumped primary care as a single workforce [9, 10]. Our study and another national study both reveal that IMGs in family medicine, the primary-care specialty most likely to distribute like the United States population, are less likely to practise in rural areas than USMGs .
Although a greater percentage of new physicians entering Health Professional Shortage Areas (HPSAs) are IMGs, the majority of these physicians are temporary visa holders . It is uncertain if this commitment to the underserved is long-term. Furthermore, previous research has revealed that IMGs are more likely to practise in markets with higher concentrations of established IMG physicians . If this trend continues, one may expect IMGs to continue to locate in urban versus rural practices.
The CTS physician survey did not identify HPSAs or visa status, so we were unable to assess the relative placement of IMGs and USMG family physicians in regard to treating the underserved, or their long-term commitment to serving these areas. Additionally, the CTS data do not allow us to perform a more refined analysis of exactly where in urban areas these physicians are located, as other studies looking at IMGs of all specialties have done [7, 20].
More IMG practices are open to all new Medicaid and Medicare patients, and a greater percentage of their revenue is derived from these patients
This trend has also been established in comparing IMGs and USMGs in psychiatry . The greater service of Medicare and Medicaid populations by IMG family physicians suggests they have a greater dependence on publicly financed programmes and that they plan an important role in providing access to care for Americans covered by these federal programmes.
More IMGs are dissatisfied with their overall medical careers
Previous studies have linked career dissatisfaction with a perceived inability to provide high-quality care . Although more IMGs in this study are dissatisfied than USMGs, they report no less ability to deliver high-quality care to their patients. Furthermore, more IMGs report having adequate time and ability to develop continuing relationships with their patients than their USMG colleagues. Given the link between career satisfaction and quality of care, it is important to consider what potentially increasing the percentage of dissatisfied physicians means for the future of family medicine and the patients they serve. While it is beyond the scope of this study, it is important to further examine this difference in order to discern potential etiologies and solutions to improve physician satisfaction.
In reviewing the clinical vignettes, we noted several situations in which IMGs order more tests, refer more patients or require more office visits than USMGs. These differences were statistically significant for half of the vignettes, but it is uncertain whether this reflects appropriate care or if the differences were clinically significant. To our knowledge, no research has been published examining the referral patterns and service use practices of IMGs and USMG physicians in the United States. This area deserves further examination, as there may be important health care cost and utilization effects to consider if differences between the groups do exist.
As previously stated, it is important to note that there are no significant differences between IMGs and USMGs regarding their self-rated ability to deliver high quality care to their patients. A greater percentage of IMGs feel that they have adequate time to spend with their patients and that they are able to develop continuing relationships with them.
There are several limitations to our study. The cross-sectional nature of this study precludes our ability to demonstrate causal relationships between variables in addition to the potential for selection effects and the inability to assess possible maturation effects. Reporting error and recall bias are always potentials when examining survey data. Furthermore, the data in this study are subjective reports given by physicians themselves, as opposed to objective practice analyses and clinical outcomes.
We are also unable to differentiate between IMGs who were born in the United States and those who were foreign-born. Since United States-born IMGs and "Fifth Pathway" students account for increasing numbers of PGY-1 family practice residents , it would be important to determine whether differences exist between this group and their foreign-born counterparts.
The linkage of general practitioners with family physicians by the CTS may affect some of the results of this paper. Although we know the participants were self-reported family physicians or general practitioners, we do not know the primary focus of their practices (traditional practice, emergency physician, occupational medicine, etc.).
In addition, the clinical vignettes were designed by the CTS and their validity is untested. We include them because they offer a unique viewpoint into clinical decision-making that is often not available in data sources.
Our data were collected in 1996 and 1997. This is the most recent nationally representative data source that oversampled primary-care physicians and examined the specific clinical information we needed, including the clinical vignettes. Although the CTS has collected physician survey data in subsequent years (1998–1999, 2000–2001), neither of these data sets include the pertinent clinical information provided in the vignettes of the 1996–1997 data set. In addition, this time frame allows us to obtain a snapshot of family practice physicians at the time when USMG interest in family medicine was peaking and the number of IMGs entering the field was poised to increase, thereby providing a baseline with which to compare more recent studies on this issue.
IMGs were just 13.4% of the CTS sample – less than their percentage in the overall family medicine workforce. We cannot know whether there was a disproportionately lower response rate from IMGs or if IMGs were a smaller proportion of the workforce within the sampled areas. While this may affect external validity, we don't anticipate that non-respondent IMGs would be more satisfied, or less likely to serve Medicare and Medicaid patients. The characteristics reported in this study may have changed over the past nine years.