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Join us for a conversation with George M. Abraham, former president of the American College of Physicians (2021-2022) and a professor of medicine. We’ll explore the vital role of international medical graduates (IMGs) in the U.S. health care system. Discover how IMGs enhance cultural competence, improve access to care in underserved areas, and contribute to academic medicine and research. George shares his perspectives on the challenges IMGs face, their impact on internal medicine, and strategies to ensure equal opportunities within the physician workforce.

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 discusses the KevinMD article, “Everyone under the big tent: the international medical graduate.”

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Transcript

Kevin Pho: Hi, and welcome to the show. Subscribe at KevinMD.com/podcast, and get CME for this episode by clicking on the CME link in the show notes. Today we welcome George M. Abraham. He’s a former president of the American College of Physicians and is currently a professor of medicine at the University of Massachusetts Medical School. Today’s KevinMD article is “Everyone under the big tent: the international medical graduate.” George, welcome to the show.

George M. Abraham: Thank you, Kevin. Honor to be here.

Kevin Pho: So let’s start by briefly sharing your story and journey.

George M. Abraham: Absolutely. So as an international medical graduate, I came to this country, I hate to say it, almost 28 years ago now. And I was applying to U.S. residency programs at the time when we were still doing it on pencil and paper, and getting those glossy brochures mailed to our homes, and to every large university program that I’d applied to.

And for background, I’d finished medical school, I’d done a full residency in internal medicine, I’d spent a fellowship and then three years as a faculty member at one of the top 10 medical schools in India. And when I applied, most of those university programs wrote back saying, oh, we get a number of qualified applicants, unfortunately you’re not one of them, so you can’t be a part of our residency program.

And so after almost 100 applications came back negative, I started applying to more community-based programs, and finally gravitated to a community-based teaching hospital affiliated with the University of Massachusetts called Saint Vincent Hospital. And so that’s where I ultimately trained. Actually the program director at my interview said he’d even be willing to waive a year of training, because I met the ABIM’s criteria for waiver of a year of training given my background.

And then I stayed on there as a faculty member. And as I rose through the ranks 25 years later, as I’ve been a mentor to a number of other international medical graduates coming into the institution and training in our residency program, I found the same challenges. Because when they apply for fellowships they get turned down at a number of different places, much less than before, simply because I think increasingly programs have started accepting international medical graduates.

But that set me thinking, in my year as president of the American College of Physicians, where I’m leading an organization which has about 163,000 members, medical students, residents, faculty, practicing physicians all around the globe. And I started saying, how is it that people who form one out of every four physicians in this country, an international medical graduate from all parts of the world, how is it that they are still not mainstream and they’re struggling to get accepted? And that led to focusing on the topic and this attention to it. And I’m glad to have initiated the conversation, because it’s definitely caught fire.

Kevin Pho: All right. So let’s talk about that article. It’s titled “Everyone under the big tent: the international medical graduate.” For those who didn’t get a chance to read your article, tell us what it’s about.

George M. Abraham: Yeah, so it’s basically focusing on what value an international medical graduate brings to the U.S. health care system. And that’s where I’ve quoted a couple of studies which have been done, which have looked at quality of care issues, which have been one of the things people have focused on, because international training may not be on par with that in the United States.

It’s focused on, over the years, contributions of international medical graduates to the U.S. health care system in terms of research, where 18 percent of research is conducted by international medical graduates. And that, in spite of funding issues where non-citizens don’t get NIH funding for example, they’ve still contributed to scholarly work, they’ve contributed to the overall care.

There is ample data which shows that international medical graduates tend to gravitate to rural areas or underserved areas as a form of their visa fulfillment requirements. And that in general, one in four physicians are international medical graduates. In the world of internal medicine it could be 30 to 35 percent of physicians are international medical graduates. In fact nephrology for example, or renal medicine, there are more IMGs than U.S. medical graduates actually practicing in the U.S. today, so one of the first specialties which has flipped in terms of demographic.

So essentially trying to demonstrate that they are no longer a small minority but increasingly becoming a large majority. They fulfill a need in terms of a shortage of personnel as we see that, and they fulfill certain important economic and scholarly contributions to the country and to the health care system. And so that’s what I wanted to highlight.

Kevin Pho: All right. Tell us about the key challenges that international medical graduates face in say securing residency positions, and how do these challenges affect their trajectories?

George M. Abraham: Yeah, great question. Because a number of them coming in, it’s not a shoo-in, as you heard my story and as you’ve heard stories from many others over the years.

So they are competing in a large pool. So if I take my own residency program, we have 75 residents in medicine, we take 25 people a year, we get 5,500 applicants, out of which almost 5,200 or 300 might be international medical graduates and a small proportion are U.S. medical graduates. But in that large pool they are competing, so there’s about a 20 to one chance that one of them will make it into our program. That’s number one. So getting into a program is challenging.

I think definitely there is the disparity, because it’s not a level playing field. They get to apply to programs which are more community-based, et cetera. Their shot at a university based program is much less. And part of it may be their accent, part of it may be their background, whatever it is.

There have been studies done which have looked at why programs which are more university based or larger programs, why is it they don’t choose international medical graduates. And generally the opinion of program directors has been that, you know, it’s considered one step below, you chose an international medical graduate because you couldn’t match a U.S. medical graduate to your program. So therefore there’s a stigma associated, so to speak, which drives program directors to push more for U.S. grads instead of international grads.

And then once they get into the program, they are on a visa which is a training visa or a non-immigrant visa. So they need to then secure a job and find out various means by which they can get into the health care system, as well as secure a permanent residence in the country and ultimately citizenship. It’s much more arduous, it’s more subjective, because they’re subject to all the visa restrictions in the country and for entry and exit and so on.

They leave their families behind. So we’ve seen that where some of the residents struggle with the workload and acclimatization to the culture, and not having the support system that they would have expected. There are challenges when during COVID for example, or after, when residents were at the front lines, were either seriously ill or unfortunately even some had succumbed to their illness. What happens to their families who are no longer employed here? So therefore how do they go back to the country, their financial implications?

So there have been a number of areas that we’ve been focusing on, and organized medicine, be it the AMA, the ACP, all other organizations, are now looking at that, to say how can we best get them into the system, acculturate them better, iron out some of these roadblocks, challenges, and level the playing field a little bit more, since they are now a larger majority of our workforce than they were before.

Kevin Pho: I want to talk about that stigma. So even today in 2024, where international medical graduates, they could have been practicing physicians in their own country for years, there is still a stigma against international medical graduates. When you talk to program directors today, is that really true?

George M. Abraham: Unfortunately, yes. Yes. Admittedly nobody will overtly say that, but subjectively, or in an anonymized survey, people will still admit to the fact that that does exist. And which is why there are some programs who never take international medical graduates, for those reasons.

Kevin Pho: Now, you mentioned that international medical graduates tend to match in rural or medically underserved areas. So what are the implications of that trend for our health care delivery system?

George M. Abraham: Yeah, wonderful question. So two things that I’d like to highlight. Number one, the fact that as part of that visa waiver fulfillment, the U.S. government has set it up in the way that if you were to work in a medically underserved area, then the requirement to return to their home country is waived and they get to stay in the country.

So we fulfill a big need, which is, if you look at the disparity in health care between urban areas and rural areas, definitely rural areas are far more underserved in terms of the density of the physician population, trained physicians, competent physicians, et cetera. So that’s one big area that they fulfill, and so therefore we at least partially level the playing field and decrease that disparity between urban and rural areas.

Number two, there’s been a fair degree of conversation going on nationally now about many states having proposed something called an alternate or an additional pathway to licensure, where proposals have been made to bring in international graduates, maybe from select countries or at least with a background of training similar to mine, some degree of a postgraduate degree and some degree of experience and expertise, and directly bring them into the country, bypass U.S.-based residency and ACGME based residency, and directly transplant them into an area, maybe a rural underserved area, so as to help address some of the disparities.

Now there are several challenges with that which may be the conversation of another podcast, definitely not for today. But suffice it to say, there is a need, that need is fulfilled with this category of people. Whether they are better served by having people trained in the U.S. where they get to acclimatize to our culture, our type of medicine, the way it’s practiced and its nuances, before they are placed there, definitely seems to be a better solution than somebody directly transplanted and expected to thrive.

But the long and short is, they fulfill a vital area of need, which is geographic areas where there is an underrepresentation, is definitely an area which is fulfilled by international grads.

Kevin Pho: So you mentioned a little bit about the adjustment that international medical graduates have to make culturally, perhaps with the language. What are some of the resources to smooth out that transition when they come to the United States?

George M. Abraham: Wonderful question. So the Educational Commission for Foreign Medical Graduates, ECFMG, has put together a little workbook, they’ve got some videos, et cetera. But residency programs have developed some sort of an acculturation program.

So later this afternoon I will be meeting with our new trainees who are here in their orientation program, to talk about specific challenges as an international medical graduate. How do you get a Social Security number, how do you open a bank account, how do you buy a car, how do you choose health insurance? And then cultural norms, the idioms that we use, how do we interact with patients, how do we break bad news, how do we keep confidentiality, how do we interact with other members of the health care team, be it nurses, allied health professionals, et cetera. These are all quite new to people coming from other parts of the world where some of these don’t exist.

And so getting to know that, even, how do you blend in with the rest, knowing who are your local sports teams, what are things that you cheer for, what’s appropriate to say, what’s not appropriate to say, how do we work together in teams? We are no longer the single physician alone working, but we’re working as part of a health care team. How do we get along with others, how do we interact with people of the opposite gender or people with gender diversity, et cetera? So lots of different things.

So we do a two-hour sort of session answering questions and doing that, and most programs, or many programs across the country, do that. We pair them with buddies who’ve already been here, who are their seniors, who can sort of walk them through some of this.

And so this is the way we sort of do a crash course training as to how to get them into the system and how to blend in better, fit in better, because that would help them get much easier into focusing on the actual content of medicine that they’re expected to learn, but at the same time not feel that they’re a total misfit in a group of physicians or other health care professionals.

Kevin Pho: So for those international medical graduates who are listening to you here on this podcast and they’re considering a residency position in the United States, tell us some of your top tips that you have for them, whether the United States in the first place is a good fit for them and how to smooth that transition. What are some of your tips for them?

George M. Abraham: Yeah, great question. There are so many parts of the world who are begging for physicians, and so immigration to many other parts of the world has become easier than coming to the U.S. I think the value of training in the U.S. has its own charm. Having trained in a British based system and then coming here, I appreciate that difference.

But at the same time, you know, it’s working hard. Obviously the examinations have become a little higher bar now, just because the number of applicants, plus the fact that they’re online. So working hard with clearing examinations. Again, looking at lots of tips about how to interview for a residency program. Most of these interviews are now virtual, so we’re talking on Zoom. The elevator pitch, so to speak, how do I sell myself as a competitive candidate in the eyes of a program director in the 20 minutes or 30 minutes that I get to interact with one or more faculty from a particular residency program.

Then in the program, how do I really work hard to establish myself, but also establish my career goals and where I want to go with next. And I would say do not let your residency, your fellowship training, be the end of your training, but really look to enter leadership, both locally, regionally, or nationally. It’s important for people to feel that they are recognized, to feel that they are empowered to lead. Most importantly, that’s the way you pave the way for others to follow in our footsteps.

Kevin Pho: So what kind of trends do you see in say the next coming years in terms of the role international medical graduates are going to be playing in our workforce?

George M. Abraham: One, we are seeing tremendous gender diversity, so we see a lot more international grads coming in, both men and women, which is wonderful. We see a diversity of different countries coming in, which is also wonderful, because it enriches our culture and definitely makes us much more broad thinkers, which we should be.

It makes us look much more like our patients, because our patients are so diverse in terms of their ethnicities, language, et cetera, the religious beliefs, et cetera, that we are better able to blend, because they relate better to people who look like them as opposed to people who don’t look like them.

And finally, we are seeing increasingly the focus on international medical graduates, so the increasing entry into leadership, increasing entry into responsible positions, all of which are so encouraging, because this then helps to level the playing field better and make the next generation feel more comfortable and at home here.

Kevin Pho: What about the role in terms of the primary care shortage? What’s the role of international medical graduates in addressing that specific aspect?

George M. Abraham: I’m a big fan of that, being a primary care physician myself, I do a lot of primary care and I’m a big fan of primary care. And that’s an excellent question. We do need primary care physicians, so we really would like to see more international graduates participate in that as well, because that’s a given need.

This was the alternate or additional licensure pathway that I was alluding to earlier, was designed, or is designed, or at least envisioned, to sort of address that primary care shortage, especially in underserved areas. And I think, so that needs to be, as we look to more international grads entering the health care workforce here in the U.S., we need to pick up that increased participation, not only to be another subspecialist, but really to pick up in primary care as well, so that that is also equally well filled.

Kevin Pho: We’re talking to George M. Abraham. He’s a former president of the American College of Physicians, currently a professor of medicine at the University of Massachusetts Medical School. We’re talking about his KevinMD article “Everyone under the big tent: the international medical graduate.” George, we’ll end with some of your take-home messages that you want to leave with the KevinMD audience.

George M. Abraham: Yes. So as I would say to all our international medical graduates, please think about your participation in not only responsible health care and training, to hit some of the underserved areas, that is the primary care as was alluded to earlier, to engage in leadership, and most importantly to be a role model and to pave the way for others.

So I’m going to end off with a quote from the actual article I wrote, which Kevin alluded to, and it goes this way, and I quote: the internal medicine community is broad and varied, with the 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.

Thank you, Kevin, for highlighting this important area, and your presentation and podcast here today I’m sure will be further helpful in the conversation as it continues to evolve. And I’m sure every IMG will relate to this. Thank you for the opportunity for this wonderful conversation.

Kevin Pho: Well, thank you so much for sharing your perspective and insight, and thanks again for coming on the show.

George M. Abraham: Thank you.