Advancing diversity: the role of international medical graduates

A physician workforce that reflects the population it serves has been highlighted as one solution for persistent race-based health disparities.¹ Efforts to diversify the gastroenterology and hepatology workforce in the USA have, historically, focused on improving diversity among fellows and faculty and increasing the number of potential trainees at the medical school and residency levels.¹ Non-US international medical graduates (IMGs) help to diversify the US gastroenterology and hepatology workforce, but several issues need to be addressed so that the effect of IMGs on diversity is sustained.

IMGs currently constitute 25% of the US physician workforce. Although IMGs cannot contribute to increased representation of Native Americans, between 2000 and 2005, approximately 45% of Hispanic and Latinx and 32% of Black medical graduates in the USA were IMGs.² IMGs are more likely than US medical graduates to practice in underserved areas and treat racial or ethnic minority and lower-income populations.³ However, data about the proportion of IMGs in gastroenterology and hepatology are nonexistent and there are several barriers to IMGs joining the gastroenterology and hepatology workforce.

Most IMGs require visa sponsorship to participate in graduate medical education.⁴ This route most commonly involves a J-1 visa, as the process is generally easier, faster, and cheaper than for other visa types. However, in a survey of internal medicine programme directors, the specialty with the highest proportion of IMGs, 41% of respondents seldomly ranked and 20% never ranked IMGs as potential candidates for their medical residency programmes.⁵ Because internal medicine programme completion is required for gastroenterology and hepatology fellowships, IMGs who do not meet this prerequisite are ineligible to apply for these fellowships.

Despite having similar US Medical Licensing Examination scores, IMGs are more likely to obtain medical residency positions in community based programmes than US medical graduates, who are more likely to obtain positions in university hospital based academic programmes.⁶ Although community programmes provide excellent training, they could involve fewer interactions with gastroenterology and hepatology faculty who could serve as mentors. Also, compared with academic programmes, community programmes traditionally have fewer resources to do clinical or translational research. Cumulatively, these factors might render IMGs less competitive for gastroenterology and hepatology fellowships. For IMGs who obtain a gastroenterology and hepatology fellowship, there might be additional funding restrictions that decrease opportunities for those interested in research-intensive academic careers.

After completing gastroenterology and hepatology fellowships, IMGs on J-1 visas can obtain a visa waiver enabling them to practice medicine in the USA. These waivers typically require IMGs to work in a federally designated medically underserved region for 3 years.⁴ Although this waiver has been instrumental in addressing the health-care needs of individuals living in such regions, it can limit the ability of IMGs to pursue specialty fields, including gastroenterology and hepatology.³ IMGs who obtain gastroenterology and hepatology faculty positions are ineligible for federal career development awards, other than the US National Institutes of Health (NIH) K99/R00 programme, because of NIH citizenship requirements. These funding opportunities can have a pivotal role in the early career of an investigator.⁷

Several interventions can be considered to address these challenges. First, visa acquisition is an arduous process for applicants and sponsoring agencies or institutions. Although applicants might be motivated to navigate the system, the US Department of State should provide a streamlined and cost-effective process for the US Educational Commission for Foreign Medical Graduates and institutions that sponsor physician visas. Doing so could reduce the burden of the visa acquisition process on medical residency programmes and lead to favourable consideration of IMGs. Additionally, the Association of American Medical Colleges could consider masking an applicants’ visa status in the earlier stages of the programme application process, which could reduce selection bias based on visa status and lead to more favourable medical residency rankings for IMGs.

Second, the US Citizenship and Immigration Services and US Department of Health and Human Services should consider expanding the mechanisms for postgraduate medical education employment authorisation and legal permanent residency (ie, the green card). In addition to meeting community primary care needs, priority should also be given to IMGs who will contribute to the racial and ethnic diversity of the US physician workforce, including those who wish to pursue medical specialties or academic positions.

Third, the NIH should revisit their restrictions on grant eligibility based on US citizenship. Although some people argue that NIH grants are funded by US taxpayers, and therefore should only be given to US citizens, IMGs undoubtedly contribute through taxed earnings. Ultimately, scientific breakthroughs, regardless of who achieves them, benefit all citizens.

Improving the integration of IMGs into the US physician workforce can place a considerable strain on the countries from which these physicians originate. Various mitigating strategies for this brain-drain process have been proposed and require careful consideration to ensure mutually beneficial and equitable arrangements.⁸ However, in the interim, IMGs have and will continue to pursue career advancement in the USA. Addressing the challenges outlined in this Comment will empower IMGs as they contribute to patient care and research. A notable by-product of a system that works better for all, could in fact be increased diversity in gastroenterology and hepatology.