International medical school graduates are more likely to be primary care physicians than their U.S. medical school counterparts, says the president of an international medical school.
With the country's physician shortage forecast to worsen for more than a decade, international medical school graduates could play a key role in addressing staff shortfalls.
The physician shortage could expand to nearly 122,000 clinicians by 2032, including a shortfall of about 55,000 primary care physicians, according to the Association of American Medical Colleges. In 2017, the AAMC estimated the overall physician shortage at 20,400 clinicians.
To gauge the impact of international medical school graduates on the physician shortage, HealthLeaders recently spoke with G. Richard Olds, MD, president of St. George's University in True Blue, Grenada, in the West Indies. St. George's draws students and faculty from 140 countries. According to St. George's University website, the university "has become the second-largest source of doctors for the entire U.S. workforce."
Before taking the top executive role at St. George's, Olds was the vice chancellor for health affairs and founding dean of the School of Medicine at the University of California, Riverside. He earned his medical degree at Case Western Reserve School of Medicine in Cleveland and received his internal medicine training at Massachusetts General Hospital in Boston.
Following is a lightly edited transcript of Olds' conversation with HealthLeaders.
HealthLeaders: What is driving the physician shortage in the United States?
Olds: There's a lot of talk about the doctor shortage, and there's no question there is a doctor shortage. But more importantly, there is a marked maldistribution of doctors, and a marked maldistribution of specialties that doctors go into. Although we are short of doctors overall, we are extremely short of doctors in rural areas of the United States and urban underserved areas. We actually have a surplus of doctors in many affluent areas of the United States.
The other problem is that the doctors trained in the United States largely become specialists. So, we have a growing shortage of primary care doctors.
HL: Why do U.S. medical schools produce high numbers of specialists?
Olds: If you look at U.S. medical schools, about 70% of the graduates specialize. They not only train at university hospital tertiary centers, the vast majority of faculty at U.S. medical schools are specialists. So, not surprisingly, they train people to be like them.
HL: Is there more of an emphasis on primary care training at international medical schools?
Olds: Yes. At our school, we largely train at community hospitals, and our faculty are primarily primary care faculty. So, we have the reverse statistic—70% of our graduates go into primary care and only 30% specialize.
We need about half of all medical school graduates to go into primary care. So, one of the reasons why international medical schools will continue to be important is that if the U.S. medical schools are going to turn out mostly specialists, then the primary care doctors are going to be mainly international medical school graduates. Until the U.S. medical schools change their statistics, there will always be a need for international medical school graduates.
HL: Are international medical school graduates who end up practicing in the United States mainly foreign-born individuals?
For international medical graduates, the assumption of many people is that these are all foreigners, which is not true. More than half of international graduates practicing in the United States are U.S. citizens, many of whom just missed getting into U.S. medical schools. They go to international medical schools, do everything that they would have done in a U.S. medical school, then return to do their residencies in the United States and, ultimately, practice in the United States.
HL: Why do you believe that international medical school graduates are more likely to gravitate to underserved areas of the country than U.S. medical school graduates?
Olds: About 25% of the doctors in the United States are international graduates—we're not talking about a rare occurrence. In rural areas and urban underserved areas, that percentage goes up to as high as 40%. So, international graduates are disproportionately going into primary care specialties and disproportionately practice in underserved areas, which is why they are crucial in trying to address the real doctor shortage—maldistribution by specialty and geographic area.
International medical school graduates who train in the United States such as the ones at my school train largely in federally qualified healthcare centers and community hospitals. So, they are taught medicine in settings where they ultimately practice.
In addition, many U.S. medical school students come from affluent communities and ultimately practice in those geographic areas. So, the differences in who gets into medical school and the differences in where we train them clinically are major reasons why international medical school graduates end up practicing in underserved areas of the United States.
HL: Are there benefits to having diversity in the U.S. physician workforce beyond helping to address the physician shortage?
Olds: St. George's doctors train with doctors from all over the world, which makes them more skilled at taking care of patients from a variety of ethnic backgrounds. So, both from the standpoint of better training of doctors to take care of all types of patients and from the patients' standpoint of liking to have doctors who come from a diverse background, international medical school graduates are better positioned than U.S. graduates. But having diversity among physicians and all healthcare professionals is good for our country.
HL: Has the Trump administration's efforts to reduce immigration impacted the ability of foreign-born international medical school graduates to work in the United States?
Historically, hospitals short of doctors could sponsor foreign-born physicians through an H-1B visa process. However, in their attempt to decrease immigration, the current U.S. government has unfortunately made it more difficult for international physicians to come to the United States, despite that we are desperate for more primary care doctors to work in underserved areas.
Right now, the visa situation is still reasonable. Most international medical school graduates can still train and practice in the United States, but the situation with H-1B visas has made it more difficult and will exacerbate the primary care physician shortage in the short run.
Christopher Cheney is the senior clinical care editor at HealthLeaders.
The U.S. physician shortage is most severe in the primary care field, with an estimated shortfall as high as 55,000 primary care doctors by 2032.
About 70% of U.S. medical school graduates go into specialty fields.
In contrast, most graduates of international medical schools practice in primary care.