It's a common perception that physicians trained by foreign medical schools aren't as skilled as doctors trained by U.S. medical schools. But that's a false assumption, according to a report published in Tuesday's edition of the journal Health Affairs.
The quality of a physician's skill seems to depend more on whether the doctor educated abroad was an American citizen or a foreign one at the time he or she entered medical school, said the author, John J. Norcini, president and CEO of the Foundation for Advancement of International Medical Education and Research.
Doctors who were both foreign citizens and foreign medical school graduates had lower patient death rates than doctors who were U.S. citizens and foreign medical school graduates.
One in four physicians now practicing in the U.S. received medical education abroad.
Norcini and colleagues looked at in-hospital death records of 244,153 patients hospitalized at 184 Pennsylvania hospitals between 2003 and 2006. Here, more precisely, is how the review broke down, based on severity-adjusted death rates for patients with either congestive heart failure or who had suffered an acute myocardial infarction:
- Doctors who were foreign citizens at the time they entered a foreign medical school had a "significantly lower" mortality rate (5%).
- Doctors who were U.S. citizens at the time they entered a U.S. medical school had a higher mortality rate, (5.5%).
- Doctors who were U.S. citizens at the time they entered a foreign medical school had the highest rate, (5.8%).
The study was supported by the Educational Commission for Foreign Medical Graduates.
"Patients of foreign citizens who were international medical graduates had a 16% reduction in mortality compared to U.S. citizens who went abroad for their medical education," Norcini said in an interview.
The report discovered two other important quality distinctions. Mortality rates were said to be significantly lower for patients whose doctors had more recently undergone their training, regardless of where they went to medical school. Severity-associated death rates also were lower for patients whose doctors were board-certified.
Also, board certification and more recent graduation from medical school were associated with shorter patient hospital stays.
"Holding all other variables constant, increasing years since medical school graduation was significantly associated with longer stays, while treatment by a cardiologist or physician holding a specialty board certificate was significantly associated with shorter stays," Norcini and colleagues wrote.
That distinction was even greater than the variations between doctors educated at home versus abroad, Norcini says.
The study also looked at length-of-stay as a measure of quality, and found that patients of doctors who were U.S. medical school graduates had the shortest lengths-of-stay and the patients of U.S. citizen doctors who were international graduates had the longest.
"The take-home lesson is to look for a doctor with board certification who's involved in a maintenance of competency program. That's more important than where the doctor went to medical school."
Norcini, however, is worried about the implications of his report on the current growth of U.S. medical schools now underway, estimated to increase the number of student spots by between 20% and 25%.
As that happens, some U.S. citizens who previously went to foreign medical schools because they couldn't get into U.S. medical schools may now be accepted by U.S. medical institutions, Norcini said.
"Part of the performance difference may be due to variability in the quality of the medical schools that U.S.-citizen international graduates attend," Norcini wrote in the journal article. "But to some degree, it may also reflect their ability. It will be important to monitor this possibility, since the pool of U.S. applicants to international schools is a potential source of students for U.S. medical schools as they expand."
Norcini concludes that foreign-trained doctors play a valuable role in filling significant provider shortage gaps throughout the country. However, while medical school spots may be expanding, residency programs are not increasing at the same rate.
"If this continues, the current physician shortages will persist and the numbers of foreign trained doctors will likely decrease significantly" because they won't find a residency spot for their training. Instead, those spots will be taken up with American-educated medical students who will likely have priority.
The authors acknowledged that the study has several important limitations. It looked at only two conditions and one clinical setting—the hospital not the office practice—and in only one state. And it did not compare and contrast education at various U.S. or international medical schools.
It also could not guarantee that the physician of record may not have been the only physician to care for the patient.