Abstract
This study uses data from a cross-sectional national survey of medical residents in the US to assess whether mistreatment experiences and wellness differ between international medical graduates and US medical graduates.
International medical graduates (IMGs) represent 16% of general surgery residents.1 Mistreatment is common in general surgical training, particularly for non-White or Hispanic residents, and is associated with burnout.2 We assessed whether mistreatment and wellness differ between IMGs and US medical graduates in a national sample of general surgery residents.
Methods
Residents in Accreditation Council for Graduate Medical Education–accredited general surgery programs were administered an optional confidential survey following the 2019 American Board of Surgery (ABS) In-Training Examination, asking about mistreatment experiences (gender or gender identity or sexual orientation discrimination, racial and ethnic or religious discrimination, sexual harassment, and bullying) and wellness (burnout, thoughts of attrition, and suicidality).2,3,4 The ABS collected medical graduate status and birth country during Qualifying Examination registration. Given the use of deidentified data, the Northwestern University Institutional Review Board deemed this study exempt from review. This study followed the AAPOR reporting guideline for survey studies.
Residents were categorized as US- or Canadian-born, US or Canadian medical school graduates (USMGs); foreign national IMGs (F-IMGs); or US- or Canadian-born IMGs (US-IMGs). Residents self-identified race and ethnicity using US Census categories. Due to small sample sizes, categories were aggregated into non-Hispanic White vs non-White or Hispanic. Multivariable regression models were developed to examine the association between medical graduate status and (1) mistreatment and (2) wellness, adjusting for resident and program characteristics. All tests were 2-sided with significance set at P < .05. Analyses were performed using Stata version 17.0 (StataCorp).
Results
The study included 6956 clinically active residents who completed the survey (response rate 85.6%). Of 3067 residents from 301 programs with medical graduate status available, 2564 (83.6%) were USMGs, 297 (9.7%) F-IMGs, and 206 (6.7%) US-IMGs. F-IMGs and US-IMGs were more commonly male and trained at programs in the Northeast; F-IMGs were more often non-White or Hispanic (Table 1).
Table 1. Demographic Characteristics of Survey Respondents by Medical Graduate Status.
| Characteristic | No. (%) | P value | ||
|---|---|---|---|---|
| USMG | F-IMG | US-IMG | ||
| No. | 2564 | 297 | 206 | |
| Gender | ||||
| Female | 1095 (42.7) | 76 (25.6) | 65 (31.6) | <.001 |
| Male | 1469 (57.3) | 221 (74.4) | 141 (68.5) | |
| Race and ethnicitya | ||||
| Non-Hispanic White | 1680 (65.5) | 97 (32.7) | 126 (61.2) | <.001 |
| Non-White or Hispanic | 884 (34.5) | 200 (67.3) | 80 (38.8) | |
| PGY level | ||||
| PGY3 | 733 (28.6) | 89 (30.0) | 64 (31.1) | .82 |
| PGY4 | 951 (37.1) | 102 (34.3) | 71 (34.5) | |
| PGY5 | 880 (34.3) | 106 (35.7) | 71 (34.5) | |
| Has children | ||||
| No | 1870 (72.9) | 209 (70.4) | 156 (75.7) | .41 |
| Yes | 694 (27.1) | 88 (29.6) | 50 (24.3) | |
| Relationship status | ||||
| Married/relationship | 2063 (80.5) | 229 (77.1) | 163 (79.1) | .37 |
| No relationship | 501 (19.5) | 68 (22.9) | 43 (20.9) | |
| Program type | ||||
| University-based | 1511 (58.9) | 160 (53.9) | 67 (32.5) | <.001 |
| Independent/military | 1053 (41.1) | 137 (46.1) | 139 (67.5) | |
| Geographic region of program | ||||
| Northeast | 739 (28.8) | 132 (44.4) | 103 (50.0) | <.001 |
| Southeast | 537 (20.9) | 45 (15.2) | 28 (13.6) | |
| Midwest | 589 (23.0) | 75 (25.3) | 43 (20.9) | |
| Southwest | 320 (12.5) | 26 (8.8) | 21 (10.2) | |
| West | 379 (14.8) | 19 (6.4) | 11 (5.3) | |
Abbreviations: F-IMG, foreign national international medical graduate (IMG); US-IMG, US- or Canadian-born IMG; USMG, US medical school graduate; PGY, postgraduate year.
Due to small sample sizes, race and ethnicity is expressed as a binary variable: non-Hispanic White vs non-White or Hispanic.
After adjusting for resident and program characteristics, F-IMGs were less likely to report sexual harassment and bullying compared with USMGs; however, there was no difference between US-IMGs vs USMGs. F-IMGs and US-IMGs were less likely to report burnout than USMGs. There were no differences in reports of other mistreatment types, thoughts of attrition, or suicidality between groups (Table 2).
Table 2. Resident and Program Characteristics Associated With Mistreatment and Wellnessa.
| Outcome | USMG | F-IMG | US-IMG | ||
|---|---|---|---|---|---|
| Rate, No./total No. (%) | Rate, No./total No. (%) | OR (95% CI) | Rate, No./total No. (%) | OR (95% CI) | |
| Discrimination | |||||
| Racial or ethnic | 535/2213 (24.2) | 83/253 (32.8) | 1.01 (0.74-1.37) | 34/179 (19.0) | 0.69 (0.45-1.07) |
| Gender | 993/2245 (44.2) | 88/255 (34.5) | 1.12 (0.72-1.73) | 69/180 (38.3) | 1.04 (0.70-1.53) |
| Sexual harassment | 778/2291 (34.0) | 47/265 (17.7) | 0.51 (0.37-0.70) | 51/182 (28.0) | 0.84 (0.59-1.19) |
| Bullying | 1537/2403 (64.0) | 145/273 (53.1) | 0.64 (0.49-0.84) | 119/195 (61.0) | 0.89 (0.66-1.21) |
| Thoughts of leaving programb | 221/2414 (9.2) | 20/278 (7.2) | 1.04 (0.60-1.82) | 16/193 (8.3) | 1.07 (0.61-1.87) |
| Suicidalityb | 108/2481 (4.4) | 10/290 (3.5) | 1.17 (0.61-2.22) | 2/200 (1.0) | 0.27 (0.06-1.15) |
| Burnoutb | 1008/2324 (43.4) | 69/268 (25.8) | 0.60 (0.44-0.81) | 60/188 (31.9) | 0.70 (0.49-0.99) |
Abbreviations: F-IMG, foreign national international medical graduate (IMG); US-IMG, US- or Canadian-born IMG; OR, odds ratio; USMG, US medical school graduate.
US medical school graduates were the referent group for all models. All models were adjusted for gender, race and ethnicity, postgraduate year, relationship status, whether resident had children, program type, and geographic region of the program. Each outcome used the maximum number of residents with data on that outcome.
Adjusted for experiences of mistreatment.
Discussion
Despite F-IMGs being more commonly non-White or Hispanic, they were less likely to report sexual harassment and bullying, seemingly contradicting prior data.2,4 Potential explanations include less mistreatment or differing perceptions of the same mistreatment. Perceptions may be influenced by cultural and/or language differences unique to F-IMGs (eg, more severe mistreatment during surgical training outside the US). Reporting of mistreatment may be affected by social desirability bias and/or concerns surrounding the survey’s ability to preserve anonymity. F-IMGs on visas may be particularly disincentivized from calling negative attention to their employers, on whom they rely to remain in the US.
Both F-IMGs and US-IMGs were less likely to experience burnout, similar to internal medicine IMG residents.5 Potential explanations include the following: (1) life and training experiences in other countries have affected IMGs’ expectations; (2) gratitude (ie, for the ability to train in the US) is protective against burnout6 and may feature prominently in IMGs’ consciousness, given the barriers they face to obtaining categorical positions (eg, unfamiliar examination formats, interviewer bias); and (3) survivorship bias, as IMGs with burnout may not attain categorical positions.
Limitations of this study include recall bias, unmeasured resident factors (eg, English proficiency), and inability to include preliminary surgical residents, who are likely particularly vulnerable to mistreatment and poor well-being. IMGs may have different experiences or perceptions of bullying, sexual harassment, and burnout than USMGs; however, mistreatment and burnout remain common among both groups. Understanding the factors associated with these differences is critical to the development of targets for reducing mistreatment and improving wellness in general surgical training.
References
- 1.Brotherton SE, Etzel SI. Graduate medical education, 2014-2015. JAMA. 2015;314(22):2436-2454. doi: 10.1001/jama.2015.10473 [DOI] [PubMed] [Google Scholar]
- 2.Yuce TK, Turner PL, Glass C, et al. National evaluation of racial/ethnic discrimination in US surgical residency programs. JAMA Surg. 2020;155(6):526-528. doi: 10.1001/jamasurg.2020.0260 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3.Schlick CJR, Ellis RJ, Etkin CD, et al. Experiences of gender discrimination and sexual harassment among residents in general surgery programs across the US. JAMA Surg. 2021;156(10):942-952. doi: 10.1001/jamasurg.2021.3195 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4.Zhang LM, Ellis RJ, Ma M, et al. Prevalence, types, and sources of bullying reported by US general surgery residents in 2019. JAMA. 2020;323(20):2093-2095. doi: 10.1001/jama.2020.2901 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5.West CP, Shanafelt TD, Kolars JC. Quality of life, burnout, educational debt, and medical knowledge among internal medicine residents. JAMA. 2011;306(9):952-960. doi: 10.1001/jama.2011.1247 [DOI] [PubMed] [Google Scholar]
- 6.Ricker M, Maizes V, Brooks AJ, Lindberg C, Cook P, Lebensohn P. A longitudinal study of burnout and well-being in family medicine resident physicians. Fam Med. 2020;52(10):716-723. doi: 10.22454/FamMed.2020.179585 [DOI] [PubMed] [Google Scholar]