Abstract
Background
The United States has more foreign-born (FB) individuals than any other country and a large international medical graduate (IMG) workforce. Yet little is known about the trends of FB IMGs matching into primary care specialties residency programs or the alignment between FB individuals and FB IMGs.
Objective
This study examined the recent trends in FB IMGs entry into primary care specialty residency programs and their distribution in relation to the US FB population.
Design
In this retrospective study, we used archives of National Resident Matching Program (NRMP) data on the main residency match from 2010 to 2022.
Main Measures
We extracted match data and program directors’ policies for internal medicine, pediatrics, family medicine, and internal medicine/pediatrics. We also extracted data on the total population and FB individuals from the US Census Bureau for each US state from 2010 to 2022.
Key Results
From 2010 to 2022, 17.2% of primary care specialty positions were filled by FB IMGs, with 22.1% for internal medicine, 11.3% for pediatrics, 10.7% for family medicine, and 3.2% for internal medicine/pediatrics. The percentage of primary care specialty positions filled by FB IMGs was significantly higher than the percentage of FB people in the US overall and 7 of 9 US regions (p < 0.001) (excepting Pacific and Mountain). The percentage of family medicine, pediatrics, and internal medicine/pediatrics positions filled by FB IMGs was significantly lower than the proportion of FB people (p < 0.001). Internal medicine had a higher proportion of positions filled by FB IMGs compared to the proportion of FB individuals in the general population (p < 0.001).
Conclusion
Distribution of FB IMGs varies in primary care specialties compared to FB people in the US. Given the importance of aligning medical education with patients’ needs, programs could take into account population demographics while assessing and admitting the applicants.
Supplementary Information
The online version contains supplementary material available at 10.1007/s11606-024-09151-5.
KEY WORDS: international medical graduates, residency, trends, United States
BACKGROUND
The United States (US) has the largest number of foreign-born (FB) individuals of any country.1 As of 2016, 44 million FB individuals (14% of the US population) were living in the US, with projections estimating 69 million (17% of the US population) by 2060.2 Studies have shown that racial and cultural concordance in a patient-physician relationship can help patients feel better understood, improve perceptions of care quality and adherence to treatment plans, and decrease hospitalization rates and medical expenditures.3–7 However, it is unknown to what degree the distribution of FB providers in the US corresponds to the overall FB population.
International medical graduates (IMGs) play an important role in the US healthcare workforce. They are more likely than US medical graduates to practice primary care and work in rural and underserved areas.8–10 Many IMGs are not FB individuals. Studies of IMGs typically aggregate IMGs who have US citizenship (US IMGs) with foreign-born IMGs (FB IMGs) who do not and are also known as non-US IMGs.11 US IMGs often study medicine abroad, because they are unable to compete to gain admission into medical schools in the US. FB IMGs come from over 100 different countries and territories12; they are diverse in their ethnic, cultural, and educational backgrounds.13–15 They also may face barriers to entering residency that are distinct from US IMGs, such as visa sponsorship and adapting to a new setting and health system.16,17 For example, delays in visa processing, uncertainties surrounding visas, and other visa sponsorship issues may make some program directors (PDs) hesitant to accept FB IMGs for residency positions.18 Others have suggested that residency programs, the point of entry for the vast majority of FB IMGs, need to do more to support FB IMGs from individual to organizational levels, including providing social support, ensuring psychological safety, and raising awareness about FB IMGs’ unique needs as migrants.19–22
FB IMGs are especially important to the primary care specialties as they disproportionately are selected for those positions and have incentives through visa programs to work in underserved areas.17,23,24 While the distribution of IMGs in pediatrics and family medicine has been studied previously,25,26 to our knowledge, IMG presence in primary care specialties has not been described in aggregate. Only one study has considered FB IMGs as a distinct group, reporting trends for family practice residencies over 20 years ago.27 Therefore, considering the diversification of the US population and the need for a similarly diverse primary care workforce, as well as ongoing challenges FB IMGs face, the current study aimed to examine the recent trends in FB IMGs entry into primary care specialty residency programs and their distribution in relation to the US FB population.
METHODS
Design
This was a retrospective study encompassing the years 2010 to 2022. We chose this time period because this was when IMGs were drawing more attention as the US workforce was expanding to address projected physician shortages and a new Educational Commission for Foreign Medical Graduates (ECFMG) requirement for medical schools was being developed and implemented.15,28,29 Also in 2010, the US Census Bureau started providing yearly estimates for state demographics. We reported this study according to the REporting of studies Conducted using Observational Routinely collected Data (RECORD) guidelines.30
We defined primary care residencies as family medicine (FM), internal medicine (IM), pediatrics (Peds), and internal medicine/pediatrics (IM/Peds) programs. We included both categorical and primary care programs for IM and Peds. We categorized IMGs as US IMGs and FB IMGs according to the definitions used by the National Resident Matching Program (NRMP), with US IMGs having US citizenship when admitted to medical school and FB IMGs not.
Variables and Data Sources
Program Director IMG Policies
We used NRMP program director (PD) surveys to assess PD IMG policies on selection into programs.31 In 2008, NRMP started publishing PD reports every 2 years, with a special PD survey in 2021 focused on the impact of the COVID-19 pandemic and its impact on the application and interview process. Reports from 2010 to 2021 included the percentage of PDs who considered applicants’ visa status when inviting them to interview. Reports from 2016 to 2022 included the percentage of PDs who never invite or rank different applicant groups, including separate values for US and FB IMGs.
NRMP Match Data
We used the NRMP’s annual Results and Data reports to extract match data.32 We extracted the number of available positions and the number of positions filled by FB IMGs for all four specialties. We used the Match Rates by Specialty and State data to extract the number of available positions in each state and the number of positions filled by FB IMGs.33 These data do not differentiate between preliminary and categorical program positions. According to NRMP data, there were no IM positions based in Alaska and Wyoming and no Peds positions in Alaska, Delaware, Idaho, Montana, North Dakota, and Wyoming during the study period. Additionally, there were no IM/Peds positions based in Alaska, Georgia, Hawaii, Idaho, Iowa, Montana, Nevada, New Hampshire, New Mexico, North Dakota, Oregon, South Dakota, Vermont, Washington, and Wyoming.
US Census Data
We extracted data on the total population and FB individuals from the US Census Bureau website using the American Community Survey (ACS) 1-year estimates for each state and year, with the exception of Puerto Rico in 2020, for which we utilized the ACS 5-year estimates as a 1-year estimation was not available.34
Statistical Analyses
We aggregated PD responses over the time period and used chi-square tests to compare the percentage of PDs who mentioned not interviewing or ranking FB IMGs to those who indicated the same for US IMGs. We applied a similar method to aggregate PDs’ responses on the importance of visa status in inviting applicants for interviews. In cases where the response count for a particular question was not provided by NRMP, we assumed the denominator to be the overall number of respondents. To evaluate trends over time, we employed separate simple linear regression models with the year as the independent variable and the percentage of positions filled by IMGs, the percentage of PDs who never invite or rank IMGs, and the percentage of PDs who consider visa status in interviewing applicants as the dependent variables. Beta estimates from the linear regression models indicate the percentage changes per year.
To understand the overall distribution of residency positions across the US, we divided the total number of positions by the population and report as available positions per 100,000 people in each state. We aggregated across the nine US regions defined by the US Census Bureau (New England, Middle Atlantic, East North Central, West North Central, South Atlantic, East South Central, West South Central, Mountain, and Pacific).35 Puerto Rico was grouped with the South Atlantic region for this analysis. For the purpose of these comparisons for each specialty, we excluded states that did not host relevant residency programs when calculating the total population, the FB population for each region, and the overall US population.
To evaluate the alignment between the percentage of FB IMGs and FB individuals overall and in each region, we aggregated data over the time period and used the chi-square test to compare the percentage of FB individuals and FB IMGs.36 We also calculated the difference between the percentage of FB IMGs within residency programs and the percentage of FB people by subtracting the percentage of FB people from the percentage of FB IMGs.
Considering the large sample size (> 300) in our study, particularly with respect to the US population and residency programs, along with evolving recommendations on the thresholds for statistical significance, we considered p < 0.005 as statistically significant to reduce the likelihood of type 1 errors and ensure the reproducibility of our findings.37,38 We used R version 4.2.3 for the analyses. We also used Tableau Desktop 2023.0 to draw the choropleth map.
RESULTS
PD Policies Regarding IMGs
From 2016 to 2022, the percentage of primary care specialty PDs who indicated they never invited FB IMGs for interviews was significantly higher than for US IMGs (27.1% vs. 10.1%, p < 0.001) as was the percentage of PDs declining to rank FB IMGs compared to US IMGs (27.4% vs. 10.9%, p < 0.001) (Fig. 1). A similar pattern was observed across all primary care specialty programs (Supplementary Table 1). There was an increasing trend in the percentage of primary care specialty PDs who never invited US IMGs for interviews over time (beta = 1.4, p = 0.008) (Fig. 1). There were no significant trends over time in the percentage of PDs from each specialty who never invited or ranked IMGs (p > 0.005) (Supplementary Fig. 1).
Figure 1.
Percentage of primary care specialties program directors who never invite IMGs for an interview nor rank them. FB, foreign-born; IMG, international medical graduate; PD, program director.
Between 2010 and 2021, 44.7% of primary care specialty PDs cited visa status as a significant consideration in inviting applicants for interviews (Supplementary Fig. 2). By specialty, visa status was cited as important by 52.0% of PDs in FM, 42.5% in IM, 38.4% in Peds, and 31.0% in IM/Peds (Supplementary Fig. 2). There were no significant trends over time (p > 0.005).
Trends of IMGs Matching into Primary Care Specialty Programs
From 2010 to 2022, between 10.2 to 14.7% of primary care specialty positions were filled by US IMGs and 17.1 to 19.9% by FB IMGs (Fig. 2). There was no significant change over time in the total percentage of primary care specialty positions filled by US (beta = 0.10, p = 0.34) and FB IMGs (beta = − 0.05, p = 0.54). There was a decreasing trend in the percentage of FM positions filled by FB IMGs (beta = − 0.5, p < 0.001), but no trends over time for other specialties (p > 0.005) (Supplementary Fig. 3).
Figure 2.
Trends of IMGs match into primary care specialties programs. Blue and red percentages indicate the proportion of positions filled by US and FB IMGs, respectively. FB, foreign-born; IMG, international medical graduate; US, United States.
Positions Filled by FB IMGs and the Percentage of FB People
Overall, there were 64.0 primary care specialty positions per 100,000 people in the US from 2010 to 2022, with Middle Atlantic region having the highest (108.5 per 100,000) and Mountain having the lowest (42.9 per 100,000 people). There were 37.3 IM positions, 14.2 FM, 11.4 Peds, and 1.7 IM/Peds positions per 100,000 people in the US during this time (Table 1).
Table 1.
Percentages of FB IMGs Matched Into Primary Care Specialties and Percentages of FB in US States During 2010–2022
| Region | Total population (1000 s) | FB population (1000 s) | Total residency positions (1000 s) | FB IMG filled positions (1000 s) | Difference percentage of FB IMGs and FB population* |
|---|---|---|---|---|---|
| United States | 325,753 | 43,254 (13.3%) | 208.5 | 35.9 (17.2%) | 3.9% |
| New England | 14,758 | 1930 (13.1%) | 15.3 | 3.0 (19.6%) | 6.5% |
| Middle Atlantic | 41,384 | 7273 (17.6%) | 45.0 | 12.2 (27.1%) | 9.5% |
| East North Central | 46,794 | 3584 (7.7%) | 34.9 | 7.7 (22.2%) | 14.6% |
| West North Central | 21,156 | 1235 (5.8%) | 12.7 | 1.8 (14.4%) | 8.5% |
| South Atlantic | 67,220 | 8486 (12.6%) | 35.5 | 5.4 (15.3%) | 2.7% |
| East South Central | 18,970 | 728 (3.8%) | 9.7 | 1.2 (12.4%) | 8.6% |
| West South Central | 39,264 | 5217 (13.3%) | 19.7 | 2.8 (14.2%) | 0.9% |
| Mountain | 23,858 | 2612 (10.9%) | 10.2 | 0.8 (7.8%) | − 3.1% |
| Pacific | 52,338 | 12,188 (23.3%) | 25.7 | 0.9 (3.7%) | − 19.6% |
FB, foreign-born; IMG, international medical graduate
*All p < 0.001
The percentage of primary care specialty positions filled by FB IMGs was significantly higher than the percentage of FB people in the US overall and in 7 regions (p < 0.001) (Fig. 3); the surplus of FB IMGs exceeded 10% for the East North Central region (difference of + 14.7%). The percentage of primary care specialty positions filled by FB IMGs was lower than the percentage of FB people in 2 regions, Pacific and Mountain, exceeding 10% for the Pacific (difference of − 19.6%) (p < 0.001).
Figure 3.
Differences between the proportion of FB primary care specialties IMGs and FB people across the US regions. FB, foreign-born; IMG, international medical graduate.
The percentages of positions filled by FB IMGs were 10.7% (4.9 out of 46.1 thousand) for FM, 22.1% (26.7 out of 121.0 thousand) for IM, 11.3% (4.1 out of 36.4 thousand) for Peds, and 3.2% (155 out of 4917) for IM/Peds. At the US population level, the percentage of positions filled was lower than FB population for FM (difference of − 2.6%), Peds (difference of − 2.1%), and IM/Peds (difference of − 11.9%) (p < 0.001). It was higher for IM (difference of + 8.8%) (p < 0.001) (Supplementary Tables 2–5).
DISCUSSION
This study characterized trends in FB IMGs matching into primary care specialty programs and their concordance with the characteristics of the US population over a 13-year period. We found variation between specialties and regions that may serve as a baseline for future studies and inform efforts to align training with the needs of FB IMGs and populations.
At the entry point for FB IMGs into US residencies, we found that PDs exhibited more favorable policies toward US IMGs than FB IMGs in spite of the fact that studies have demonstrated no significant difference in competence between US and FB IMGs.39–42 While these findings have been available in NRMP reports for years, we are unaware of anyone who has drawn attention to them. We suspect that the difference is related to FB IMGs’ need to obtain a visa. While this may be understandable from a PD’s standpoint as they face an ever-increasing number of applications to review, it also furthers inequities that FB IMGs face, including the cost of applying to many programs, challenges of the transition to the US, and the need to acculturate to a new place and health system.17,20,40 Moreover, there are signs that some others may be circumventing PDs by creating policies that allow FB IMGs to practice without requiring restarting and completing a residency in the US.24,43 Future research is warranted into PD perspectives and the implications of these policies on FG IMGs and the physician workforce.
Interestingly, despite the disadvantages that FB IMGs have compared to US IMGs in securing a residency position, there was a disproportionately high number of FB IMGs in primary care residency programs compared to regional populations, which may be due to regional visa programs and changes occurring to licensure laws.18,44 While the US physician workforce has a longstanding under-representation of some demographic groups of US citizens,45,46 it is possible this represents an opportunity for FB populations to have improved access to providers with similar backgrounds. For example, individuals born in India are among the most common immigrants to the US and FB IMGs,34,47 so they may have an easier time finding a concordant physician–patient relationship. However, FB IMGs also commonly practice in rural areas,8 which have a lower proportion of immigrants than urban settings.48 Moreover, studies have indicated that community residency programs demonstrate a more favorable approach toward IMGs.49 FB IMGs who match into community programs and practice in rural areas may need extra support to connect with their local communities to avoid negative consequences that have been previously documented.21
Amid the substantial variation in FB IMG and populations we described, the Pacific region was notable for a deficit of FB IMGs in all primary care specialties programs, which was also seen with a recent study of psychiatry residency programs.36 There has been a declining trend in the number of IMGs matching into residency programs in California, the state with the largest population and highest number of residency programs in the Pacific, which may possibly be related to the disapproval of some international medical schools by the medical board of California.50 This is particularly important considering that Pacific states are among those estimated to have the greatest physician shortages in the coming years, and there is a larger proportion of medically underserved areas in Western states,51,52 which may be hardest hit by a dearth of FB IMGs.8–10 Recently, some initiatives have been taken in Washington state to facilitate the integration of IMGs into the physician workforce and in California to facilitate the application of IMGs for residency programs.53 Similar policies may further attract FB IMGs to the region.
There are several important limitations to this study. First, the response rate of PDs to NRMP surveys varies considerably and has been less than 50% in primary care specialties. While these are the best data available for a national sample, response rates limit generalizing to every US program. Furthermore, NRMP surveys do not offer details on the characteristics of PDs, such as their program size, which would enable analytical tests to identify the factors associated with specific policies. Second, we aggregated state data by region because of the small number of programs in specific states, but this obscures variation that may occur at state or local levels or across urban–rural settings. Third, we were unable to assess the alignment of the country of origin between FB individuals and FB IMGs due to the unavailability of relevant data; moreover, perfect alignment with FB IMGs and FB populations is unreasonable, and it is unknown how much deviation may impact care. Congruency of the country of origin of immigrants and FB IMGs matching into primary care specialties and its influences should be investigated in future studies. Lastly, while there were similarities between our observations regarding the distribution of FB IMGs in residency programs with previous studies of the workforce,9 we only characterized the distribution of FB IMGs entering residency programs, not necessarily where they spend most of their careers. While IM, Peds, and IM/Peds are considered primary care specialties, many of these residents enter subspecialty fellowships where they spend their careers. We also were unable to discern reasons for differences in distribution of FB IMGs for specific primary care specialties with the data we had.
CONCLUSIONS AND FUTURE DIRECTION
The policies of programs regarding IMGs place FB IMGs at a disadvantage compared to US IMGs and there are wide variations in the distribution of FB IMGs that do not correspond to FB populations. Given the contributions to the workforce, and barriers they face to entering and assimilating into clinical training, more research should consider FB IMGs as distinct from US IMGs and begin to examine the considerable diversity within this group. The calls to centralize data sharing at institutional, state, and national levels and improve the management of the US physician workforce offers an opportunity to monitor FB IMGs as distinct groups and better attend to their needs,54,55 while also developing policies that may lead to a distribution of FB IMGs that is better aligned with population needs.
Supplementary Information
Below is the link to the electronic supplementary material.
Data Availability
We used NRMP (https://www.nrmp.org/match-data-analytics/residency-data-reports) and US Census Bureau (https://data.census.gov/) publicly available data in our study.
Declarations:
As we used publicly available data in the current study, IRB approval was not required.
Conflict of Interest:
The authors declare that they do not have a conflict of interest.
Footnotes
Prior Presentations
None.
Publisher's Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Data Availability Statement
We used NRMP (https://www.nrmp.org/match-data-analytics/residency-data-reports) and US Census Bureau (https://data.census.gov/) publicly available data in our study.