AAMC Reporter: June 2005

Ashfaq Balla, M.D., a native of Kashmir, works in a North Dakota community hospital.

Addition by Subtraction: IMGs Increase the Ranks of Patient Care and Research

By Elizabeth Heubeck, special to the Reporter

"There's a big glamour about the United States."
—Utkarsh Joshi

"I think being here will probably have a huge impact on my career."
-—Michael Kottgen

Entrenched in his surgical residency and close to becoming a neurosurgeon in his native India, 27- year-old Utkarsh Joshi abruptly left behind his certain future to pursue a medical career in the United States.

"There's a big glamour about the United States," Joshi said when asked why he chose to emigrate.

Once he entered the United States in 1989, he began the arduous process of studying for the United States Medical Licensing Examination (USMLE). And he took the only position related to his field he could find: as a research assistant in the department of behavioral pharmacology at Johns Hopkins Bayview Medical Center.

In 1994 he obtained a position as a research fellow in the department of neurosurgery at Johns Hopkins. Seeing firsthand the stiff competition among neurosurgeons in the United States and the exhausting work, he set his sights on another medical profession that allowed him to develop his long-term interest in the relationship between the brain and the mind. Today, he is a child psychiatrist providing psychiatric assessments for students in the Washington, D.C. public school system. He plans eventually to open a private practice in or near Washington, D.C.

After more than a decade in the United States, Joshi is still adjusting to the contrasting lifestyles. In India the nuclear family lives together, providing a strong base of support. Many of his compatriots express a desire to return to India but have raised a family in the U.S. and are rooted here. Despite a longing for his homeland, Joshi admitted to being spoiled by certain aspects of the United States.

"I'd experience culture shock if I were to go back permanently," Joshi said. "There are so many people, and there is so much pollution."

Joshi's decision is a popular one among foreign-born international medical graduates (IMGs). The most recent data available on IMGs in the United States reveal that they account for 25 percent of physicians in residency and fellowship programs, according to the American Medical Association. Ninety percent of all IMGs are foreign born, and 80 percent of current IMG residents and fellows are foreign born. The countries that contribute most heavily to the U.S.'s IMG population include India, Pakistan, the Philippines, China and Iran, according to the Educational Commission for Foreign Medical Graduates (ECFMG).

International applications to U.S. fellowships and residencies are not slowing down. According to statistics from the ECFMG, the numbers have risen steadily over the last 5 years.

"In 2000, the number of people applying to take Steps 1 and 2 of the clinical knowledge portion of the USMLE was 27,000. Last year, the numbers rose to 35,200. And in the first two months of 2005, the numbers were running significantly ahead of last year," said Stephen Seeling, vice president for operations at ECFMG.

Vital Role
Many international medical graduates, often seeking to extend their stay in the U.S., choose to practice in underserved areas and in so doing play an important role in filling the gaps of qualified health care professionals in these locales.

Ashfaq Balla, M.D., a native of Kashmir, is one of the thousands of international medical graduates who care for patients in underserved or rural areas. Balla works in the emergency room of Langdon, North Dakota's only community hospital as well as the town's clinic. The farming community of approximately 2,000 is a far cry from Balla's native country, which has an estimated population of 10 million.

Balla is an internist, but because of the lack of sub-specialists within Langdon, he occasionally performs procedures outside of his specialty. A surgeon comes to the community hospital every two weeks, as does a cardiologist. For the remainder of the time, Balla and the emergency room staff—two other internists and two family nurse practitioners—are on their own. The nearest subspecialty hospital is more than 100 miles away.

"In a bigger hospital, if you need help, it's a call away. Here, you've got to take responsibility and use your judgment to the best of your ability," he said.

For now, Langdon is home to Balla, his wife, and their child. He has finished half of his three-year visa commitment and is unsure about his plans for the future. He noted that the majority of his patients are at least 50 years old, and most of the young people from Langdon move away long before they reach retirement age.

Overall, IMGs practicing in underserved areas receive high marks from hospital administrators. In 2002 the University of Minnesota's Rural Health Research Center conducted a survey focused on the performance of foreign-born IMGs serving in critical access hospitals. The 388 CEOs who participated ranked IMGs' clinical skills an average of 4.35 on a scale of one to five (five being the highest); the interpersonal skills of IMGs averaged 4.02. Fifty-eight respondents added "unreservedly positive" comments.

Brain Drain
While the U.S. medical community benefits from hosting the best and brightest of students from abroad, medical educators are concerned about the impact of "brain drain" IMGs create when they leave their home countries.

"We in the United States have reaped the benefit of their [international medical students'] medical education," said Larry Smith, M.D., dean of medical education at Mount Sinai Medical School. "We get brilliant kids who fill the gap. We clearly are the winners. The losers are those countries that support the education of students who leave."

The opportunity to work and study in a leading U.S. institution draws individuals from economically advanced countries as well. Michael Kottgen, M.D., a 37-year-old from Germany's Albert-Lundwigs University in Freiburg, uprooted his wife and three children to do a three-year postdoctoral fellowship at Johns Hopkins University's Department of Biological Chemistry.

When asked what brought him to the U.S., Kottgen offers several reasons: the expertise found in U.S. labs, the extensive collaboration among disciplines, the cooperative system within laboratories and an opportunity to meet others in his field. While in the U.S., Kottgen hopes to discover why specific genes lead to autosomal dominant polycystic kidney disease. He anticipates receiving long-term professional benefits as well.

"I think being here will probably have a huge impact on my career from what I can learn technically and about how science is done here," he said. "It's also about meeting a lot of people you wouldn't otherwise meet. Most of the big conferences are here in the United States."

Kottgen is undecided about whether he plans to stay in the U.S., preferring to wait and evaluate what job offers he has both in the U.S. and in Germany. As his story illustrates, the reasons why many international medical graduates decide to come to the United States begin with their ambition.

"Many people, especially those who are competitive, try at some point in their careers to go abroad, and a lot of them go to the United States," Kottgen says.

Several initiatives such as the University of California San Francisco (UCSF) Global Health Sciences program are making inroads to reverse the problem of brain drain. It is in the process of building several training and research programs to assist developing countries. One example is the UCSF "sandwich program," whereby selected trainees from resource-poor countries complete the initial part of their medical training in their native country. Then they come to UCSF for one to two years of advanced training, after which time they return home to receive their degree.

"Brain drain has become a major problem in African countries over the last 20 years," said Halle T. Debas, M.D., executive director of UCSF Global Health Sciences. "Taxpayers educate them, and then they go. And they can ill afford the loss."

Debas cited two glaring examples. Zambia has trained 500 doctors since its independence; now only 50 remain. In Ghana 50 percent of the medical graduates have gone abroad.

"They have no professional satisfaction, no infrastructure, no colleagues, no resources," Debas says, explaining why so many medical graduates in underdeveloped countries leave their native lands.

Improving medical education in underdeveloped countries is one way to achieve this goal. And it's one that the Foundation for Advancement of International Medical Education and Research (FAIMER), a non-profit foundation of the ECFMG, has embraced. FAIMER recently established international fellowships in medical education designed to provide medical faculty from abroad with educational opportunities tailored to their home country's needs. The foundation offers 20 such fellowships annually, all with a maximum stay of one year. This guarantees participants' return to their native country.

It's a small start but one that is growing in scope as FAIMER seeks partners. The organization also plans to collaborate with the World Health Organization, which, according to John Norcini, Ph.D., president of FAIMER, views the issue of brain drain as a priority.

"We've started to work with several local medical schools," Norcini said. "This is such a large problem. We can only take a piece of it. It's got to be a collaborative effort."

FAIMER and AAMC staff are working together on two projects: a study of the educational programs of international medical schools, and an online resource of the opportunities available to U.S. medical students and faculty for exchange programs with international medical schools. In addition, FAIMER is a co-sponsor of the focus session at the 2005 annual meeting, "Beyond the Campus," featuring deans from two international medical schools.

Although efforts like FAIMER's international fellowship program demonstrate an acknowledgment of the need to share resources, the U.S. nevertheless remains reliant on IMGs to fill its needs.

"We recognize that foreign-born IMGs have and will continue to provide needed services at the graduate medical educational level and beyond," says Carl Getto, M.D., chair of the Council on Graduate Medical Education.

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