The internal medicine community is broad and varied, with a diversity of internal medicine physicians as its foundation. As we move forward as a country and as health care continues to evolve, we must embrace our diversity and afford equal opportunity to all segments of our physician workforce, including our international medical graduates (IMGs). The American College of Physicians (ACP) summed up the value of diversity in health care best when it states, “With an increasingly diverse ethnic and racial patient population in the United States, the physician population must become equally diverse in order to provide culturally competent care. International medical graduates (IMGs) contribute greatly to the diversity of the U.S. physician workforce. The College supports measures to improve conditions for those IMGs seeking to train and/or practice in the United States.”

Historically, IMGs have played a large role in internal medicine. Sir William Osler, who immigrated to the U.S. from Canada and whose observations and quotes have filled books and been frequently used in scholarly treatises, is a prominent example.

The statistical growth of IMGs in the health care system can’t be overlooked. Of more than 1 million physicians in the American Medical Association Physician Masterfile, about 25% are IMGs. The number of IMGs in practice has risen by nearly 18% since 2010, which is more than the 15% rise in U.S. medical graduates over that same time period. The largest number of IMGs hail from medical schools in India (21%), followed by the Caribbean (20%), Pakistan (6%), the Philippines (5%) and Mexico (4%).

Internal medicine has the largest share with 45,000 IMGs, but in terms of specialty, IMGs are in the greatest numbers in geriatric medicine, where they make up more than half of the active physician workforce. Interesting to note is that female IMGs have increased from 25% to 45% between 1990 and 2014. In reviewing the geographic spread, 32% of IMGs work in the South, while 28% work in the Northeast, 20% in the Midwest, 17% in the West, and 3% in territories and military bases. About 33% of IMGs work in a hospital setting, group practice follows at 31%, solo- or two-doctor practice constitutes about 20%, and the rest work in managed care, academic, or unclassified settings. About 58% of IMGs were born outside the U.S., and the other 42% of IMGs were born in the U.S. but obtained their medical degrees in another country.

A study published Feb. 3, 2017, in The British Medical Journal looked at the quality of care delivered by IMGs and suggested that after adjustment for disease type, severity, and other factors, patients treated by internationally schooled doctors had a slightly, but statistically significant, lower 30-day mortality: 11.2% compared with 11.6% for patients who received care from physicians trained in the U.S. Many IMGs tend to work in rural and medically underserved areas, often to fulfill visa obligations, and this finding indicates that IMGs not only ensure access to care for such populations, but may be more effective because of their unique position.

Several studies have also looked at the challenges of IMGs finding residency positions and demonstrated that IMGs were three times as likely to be selected into a community program as opposed to a university program. In a study published Feb 11 by the Journal of General Internal Medicine, departmental pressure, institutional priority, and reputational concerns were cited as factors influencing recruitment of IMGs to university programs.

An Oct. 17, 2017, study in Annals of Internal Medicine suggested that of the 80,000 or so academic physicians in the country, more than 18% were international medical graduates. More than 15% of full professors in medical schools in the United States were educated elsewhere, most often in Asia, Western Europe, the Middle East, Latin America, and the Caribbean. Although ineligible for National Institutes of Health funding that is granted only to citizens of this country, IMGs still managed, through collaboration, to be primary investigators on 12.5% of grants. They led more than 18% of clinical trials in the United States and were responsible for about 18% of publications in the medical literature.

The study’s authors suggest that, by some metrics, these doctors account for almost one-fifth of academic scholarship in the U.S. They further suggest that the diversity of American medicine and the conversations, ideas, and breakthroughs this diversity sparks may be one reason for our competitiveness as a global leader in biomedical research and innovation.

Many have written about diversity in health care and its effect on health care delivery in the U.S. In a perspective piece for the ACP in 2000, Barbara L. Schuster, M.D., MACP, wrote, “The United States is a country of immigrants. The vitality and spirit brought by new Americans add texture to daily life. The diversity of cultures creates complexity and challenges for those in health care. International medical graduates (IMGs) bring a wealth of knowledge of diseases not often seen in the United States, in addition to knowledge of the belief systems of the cultures from which they come. Belief systems have a significant impact on health and disease. Having diversity within the health care team allows for improved care delivery within a multicultural environment.”

Our health care system thrives on varied perspectives. Physicians and patients benefit from a rich tapestry of perspectives, backgrounds, and cultures. Our internal medicine community is diverse, and all sections of our membership must enjoy equal opportunity.

George M. Abraham, MD, MPH was ACP’s president for 2021-2022, is a professor of medicine at the University of Massachusetts Medical School, chief of medicine at Saint Vincent Hospital, and adjunct professor of medicine at Massachusetts College of Pharmacy and Health Services in Worcester, Mass. He is also the chair-elect of the Federation of State Medical Boards.

The American College of Physicians is the largest medical specialty organization in the United States, boasting members in over 145 countries worldwide. ACP’s membership encompasses 161,000 internal medicine physicians, related subspecialists, and medical students. Internal medicine physicians are specialists who utilize scientific knowledge and clinical expertise for diagnosing, treating, and providing compassionate care to adults, spanning from those in good health to individuals with complex illnesses. Stay connected with ACP on X @ACPIMPhysicians, Facebook, LinkedIn, and Instagram @acpimphysicians.