DOCTORS ON THE MOVE TRENDS, IDENTITIES, PROBLEMS DOCTORS ON THE MOVE TRENDS, IDENTITIES,...

DOCTORS ON THE MOVEDOCTORS ON THE MOVE

TRENDS, IDENTITIES, PROBLEMSTRENDS, IDENTITIES, PROBLEMS

Buz CooperBuz Cooper

AcademyHealthSan Diego

June 5, 2004

IMG TRENDSIMG TRENDS

Certification by Educational Commission on Foreign Medical Certification by Educational Commission on Foreign Medical Graduates (ECFMG)Graduates (ECFMG)

andand

Participation in Residency ProgramsParticipation in Residency Programs

RESIDENTS w/o PRIOR RESIDENCYRESIDENTS w/o PRIOR RESIDENCY1950-20021950-2002

0

5,000

10,000

15,000

20,000

25,000

1950 1960 1970 1980 1990 2000

Total PGY-1 (ACGME + AOA)

MD Graduates

IMGs in InitialResidency

DO Graduates

AMA, AAMC,AOA, AACOM

EVENTS INFLUENCING FIRST TIME IMG RESIDENTS EVENTS INFLUENCING FIRST TIME IMG RESIDENTS 1950-20021950-2002

0

1,000

2,000

3,000

4,000

5,000

6,000

1950 1960 1970 1980 1990 2000

Post Post WW II WW II

demanddemand

19981998

CSACSA

Period of Period of medical medical school school

expansionexpansion

1976 1976 Health Health

Professions Act Professions Act restrictionsrestrictions

19911991Increase in Increase in H1b VisasH1b Visas************************Proposed Proposed

exam exam changechange

19851985COBRA COBRA

restrictionsrestrictions**************************************************

Medicare IMEMedicare IME

FIRST TIME IMG PGY-1 RESIDENTS and ECFMG CERTIFICATIONSFIRST TIME IMG PGY-1 RESIDENTS and ECFMG CERTIFICATIONS

0

2,500

5,000

7,500

10,000

12,500

1982 1987 1992 1997 2002

Cert

ifica

tes

and P

GY

-1s

.

ECFMGCertificates

1st timePGY1IMGs

19911991Expanded accessExpanded access

to temporary to temporary (H1-B)(H1-B) visasvisas

19921992Proposed Proposed

exam change exam change

1998 1998 CSACSA

introduced introduced

19851985COBRA COBRA

restrictionsrestrictions

19761976Health Health

Professions Professions Education ActEducation Act 19951995

ComputerizedComputerizedexam exam

ECFMG and JAMA

TRENDS in IMGs in the USTRENDS in IMGs in the US

Who are they?Who are they?

ECFMG CERTIFICATES ECFMG CERTIFICATES 1960-20021960-2002

0

1,000

2,000

3,000

4,000

1960 1970 1980 1990 2000

So Asia, MidEast, No Africa

East Asia

Europe, Canada,Aus/NZ, Is, Africa

Latin America

USA

ECFMG

Average Number of Entering IMG Residents 1995-2002Average Number of Entering IMG Residents 1995-2002 and ECFMG Certificates 1994-2001 and ECFMG Certificates 1994-2001

0

500

1,000

1,500

2,000

IMG

s .

Certificates1994-2001

Residents1995-2002

Entering residents = 246 (viapp) From ECFMG.

IMG PGY-1 RESIDENTSIMG PGY-1 RESIDENTS1995-20021995-2002

0

1,000

2,000

3,000

4,000

1995 1996 1997 1998 1999 2000 2001 2002 2003

All other FMG

So Asia, Mid East,No Africa

USA

ECFMG

Interest in the US Among Foreign Medical StudentsInterest in the US Among Foreign Medical Students

Survey of Medical StudentsSurvey of Medical Studentsatat

Bangalore-Ramiah Medical College Bangalore-Ramiah Medical College and and

Bangalore Medical CollegeBangalore Medical CollegeINDIAINDIA

Raghu Rao and Richard CooperRaghu Rao and Richard Cooper20042004

Preliminary data analysisPreliminary data analysis

Survey of Indian Medical StudentsSurvey of Indian Medical Students

0 20 40 60 80 100

Worth leaving India for US

ECFMG exam hinders entry

CSA too expensive

US less welcoming since 9/11

US immigration laws difficult

More optimistic about India

Prefer family values in India

% Married

% Male and Female

Male

Female

Rao and Cooper, 2004%


0 10 20 30 40 50 60 70 80

Would remain in UK, % in UK

Would remain in US, % in US

Would remain away, % outside India

Other

Canada, Australia, NZ

UK

US

Thought about trainingoutside of India

Male

Female



0 10 20 30 40 50 60 70

Thought about training in other

Thought about Canada, Australia, NZ

.

Would remain in UK

Thought about training in UK

.

Would remain in US

Thought about training in US, 2004

Thought about training in US, 1998

.

Would remain after training

Thought about training outside of India

Rao, 1998 Academic PsychiatryRao and Cooper, 2004

%

International Market for Medical DoctorsInternational Market for Medical Doctors

National Primary Care Research and Development CenterNational Primary Care Research and Development CenterManchester Center for Healthcare ManagementManchester Center for Healthcare Management

Manchester, EnglandManchester, England20032003

• • A wide range of “demander countries” is looking to source a A wide range of “demander countries” is looking to source a substantial proportion of their medical labour supply from substantial proportion of their medical labour supply from outside their own health systems.outside their own health systems.

• • The hegemonic position of the USA was perceived as The hegemonic position of the USA was perceived as unassailable.unassailable.

Staying After ResidencyStaying After Residency

J1 Visa Waiver of 2-year return requirement (J1 Visa Waiver of 2-year return requirement (4,798 waivers4,798 waivers) ) Primary care or general psych in underserved area-Primary care or general psych in underserved area-three yearsthree years

State Conrad-30 Program --- State Conrad-30 Program --- up to 30 waivers per stateup to 30 waivers per state

Delta Regional Commission --- Delta Regional Commission --- 8 states, 240 counties8 states, 240 counties

Appalachian Regional Authority ~Appalachian Regional Authority ~250 counties250 counties

Veterans Administration, HHS --- Veterans Administration, HHS --- fewfew

Pending Bills: J1 waivers for specialists in hospitals serving underserved Pending Bills: J1 waivers for specialists in hospitals serving underserved Redistribution of unused waivers ---1,500 available, 1200 usedRedistribution of unused waivers ---1,500 available, 1200 used

H1b VisasH1b VisasProgram expired Sept. 30, 2003: 195K Program expired Sept. 30, 2003: 195K 65K visas 65K visasExemptions:Exemptions:

Conrad 30 waivers of J1 visa requirements while in waiverConrad 30 waivers of J1 visa requirements while in waiverResidents in a “universityResidents in a “universitySponsorship by nonprofit, university or governmentSponsorship by nonprofit, university or government

Opportunities to Remain without an H1b visaOpportunities to Remain without an H1b visaNational interest waiverNational interest waiverTourist visaTourist visaExtension of J1 to take examExtension of J1 to take examSmall business (Canadians) under NAFTASmall business (Canadians) under NAFTABill pending to exempt former J1 visa holders from H1b capBill pending to exempt former J1 visa holders from H1b cap

AFTER RESIDENCY: J1 and H1b VisasAFTER RESIDENCY: J1 and H1b Visas

• • The number of IMGs has varied with changes in The number of IMGs has varied with changes in immigration policy, reimbursement policy and immigration policy, reimbursement policy and exam-certification, but the trend has been upward.exam-certification, but the trend has been upward.

• • Half of all IMGs are from South Asia, North Africa andHalf of all IMGs are from South Asia, North Africa andthe Middle East, where visa problems are the greatest.the Middle East, where visa problems are the greatest.

• • Foreign medical students are encountering Foreign medical students are encountering increasing difficulty in accessing the US system, increasing difficulty in accessing the US system, greater demand from the UK and Canada, greater demand from the UK and Canada, more obstacles to remaining in the US after training,more obstacles to remaining in the US after training,and better opportunities at home.and better opportunities at home.

CONCLUSIONSCONCLUSIONS

Thank you.

Entering IMG Residents 1995-2002,Entering IMG Residents 1995-2002, % of GRADUATES in HOME COUNTRY % of GRADUATES in HOME COUNTRY

0%

1%

2%

3%

4%

5%

6%

7%%

of G

radu

ates

.

Adapted from ECFMG and Eckhert, 2002


0 20 40 60 80 100

Other


UK

US




CSA too expensive





% Married

% Male and Female

Total

Male

Female



0 10 20 30 40 50 60 70 80

Would remain in UK, % in UK

Would remain in US, % in US


Other


UK

US

Thought about trainingoutside of India

% Male and Female

Total

Male

Female



0 20 40 60 80 100

Would remain un UK, % in UK

Would remain in the US, % in US


Other


UK

US




CSA too expensive





% Male



0 10 20 30 40 50 60 70 80



.

Would remain in UK


.

Would remain in US

Thought about training in US

.



Total

Male

Female



0 10 20 30 40 50 60 70



.

Would remain in UK


.

Would remain in US

Thought about training in US

.




ConcernsConcernsUS-IMGs vs. Foreign IMGsUS-IMGs vs. Foreign IMGsQuality of educational programsQuality of educational programsRate of disciplinary actionsRate of disciplinary actions

HurdlesHurdlesUSMLE Steps 1, 2, 3USMLE Steps 1, 2, 3Clinical Skills Assessment (CSA) (cost, time)Clinical Skills Assessment (CSA) (cost, time)Visas to take CSA examVisas to take CSA examVisas to enter for residencyVisas to enter for residencyDecreased availability of H1b visasDecreased availability of H1b visas(195K in 2003 (195K in 2003 65K in 2004) 65K in 2004)

CompetitionCompetitionEnglandEnglandCanadaCanadaAttractiveness of native countriesAttractiveness of native countries

IMG CHALLENGESIMG CHALLENGES

ECFMG Certificates 1993-2002ECFMG Certificates 1993-2002

0

500

1000

1500

2000

2500

3000

1992 1994 1996 1998 2000 2002

South Asia

East Asia

Mid-East, No Africa

Australia, NZ, Canada,WEurope, Israel

FSU/Baltic

Latin America

Sub-Saharan Africa

ECFMG CERTIFICATESECFMG CERTIFICATES1995-20021995-2002

0

1,000

2,000

3,000

4,000

1995 1996 1997 1998 1999 2000 2001 2002 2003



East Asia

Latin America

USA

RESIDENTSRESIDENTS1995-20021995-2002

0

1,000

2,000

3,000

4,000

1995 1996 1997 1998 1999 2000 2001 2002 2003


East Asia


Latin America

USA

PERCENT of IMGs from before 1997 PERCENT of IMGs from before 1997 who are CURRENTLY ACTIVE in the AMA MASTERFILEwho are CURRENTLY ACTIVE in the AMA MASTERFILE

0

25

50

75

100%

of C

ertif

icat

e Ho

lder

s .

IMGsIMGs(all years)(all years)

Citizenship or Visa StatusCitizenship or Visa Status

0

3,000

6,000

9,000

12,000

1985 1990 1995 2000

Year

IMG

s

Exchange visitors andTemporary workers (H, J)

Permanent residents

Native US

Naturalized US

Refugees

Corrected for unknown

IMGsIMGs(all years)(all years)Visa StatusVisa Status

0

3,000

6,000

9,000

12,000

1985 1990 1995 2000

Year

IMG

s

Exchange visitors andTemporary workers (H, J)

J-1, J-2 Exchange visitors

H-1, H-1b, H-2, H-3Temporary workers

Corrected for unknown

First Time PGY-1 Residents and ECFMG CertificatesFirst Time PGY-1 Residents and ECFMG Certificates

0

5,000

10,000

15,000

20,000

25,000

PGY-1 Residents Applicants

Phy

sici

ans

IMGs not matched

IMGs newly certified

Foreign IMGs

US IMGs

Canadian seniors

DOs outside match

DOs in match

MDs outside match

MDs in match

PotentialPotential IMGs IMGs 2,000

F-IMGs F-IMGs

US IMGs US IMGs

DOsDOs

DOCTORS ON THE MOVE TRENDS, IDENTITIES, PROBLEMS DOCTORS ON THE MOVE TRENDS, IDENTITIES,...

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