DOCTORS ON THE MOVE
TRENDS, IDENTITIES, PROBLEMS
Buz Cooper
AcademyHealth
San Diego
June 5, 2004
IMG TRENDS
Certification by Educational Commission on Foreign Medical
Graduates (ECFMG)
and
Participation in Residency Programs
RESIDENTS w/o PRIOR RESIDENCY
1950-2002
25,000
Total PGY-1
(ACGME + AOA)
20,000
MD Graduates
15,000
10,000
IMGs in Initial
Residency
5,000
DO Graduates
0
1950 1960 1970 1980 1990 2000
AMA, AAMC,AOA, AACOM
RESIDENTS w/o PRIOR RESIDENCY
1950-2002
25,000
Total PGY-1
(ACGME + AOA)
20,000
MD Graduates
15,000
10,000
IMGs in Initial
Residency
5,000
DO Graduates
0
1950 1960 1970 1980 1990 2000
AMA, AAMC,AOA, AACOM
EVENTS INFLUENCING FIRST TIME IMG RESIDENTS
1950-2002
6,000
1976
Health 1991
Professions Act Increase in
5,000 restrictions H1b Visas
************
Proposed
Period of exam
Post medical 1998
4,000 change
WW II school
CSA
demand expansion
3,000
1985
2,000 COBRA
restrictions
*************************
Medicare IME
1,000
0
1950 1960 1970 1980 1990 2000
FIRST TIME IMG PGY-1 RESIDENTS and ECFMG CERTIFICATIONS
12,500
Certificates and PGY-1s .
10,000
ECFMG
Certificates
7,500
5,000
1st time
PGY1
IMGs
2,500
0
1982 1987 1992 1997 2002
1976 1985 1991 1992 1998
Health COBRA Expanded access Proposed CSA
Professions restrictions to temporary exam change introduced
Education Act (H1-B) 1995
visas Computerized
exam
ECFMG and JAMA
TRENDS in IMGs in the US
Who are they?
ECFMG CERTIFICATES
1960-2002
4,000
So Asia, Mid
East, No Africa
3,000 East Asia
Europe, Canada,
2,000 Aus/NZ, Is, Africa
Latin America
1,000
USA
0
1960 1970 1980 1990 2000 ECFMG
Average Number of Entering IMG Residents 1995-2002
and ECFMG Certificates 1994-2001
2,000
1,500
Certificates
IMGs .
1994-2001
1,000
500 Residents
1995-2002
0
s
a
ltic
ca
ia
ia
ica
A
rI
r ic
US
As
As
ri
Eu
Ba
er
Af
Af
Am
h
st
W
U/
/N
n
ut
Ea
ra
FS
n
So
st
tin
Ca
ha
Ea
La
a
Entering residents = 246 (viapp)
id
NZ
bS
M
From ECFMG.
Au
Su
IMG PGY-1 RESIDENTS
1995-2002
4,000
All other FMG
3,000 So Asia, Mid East,
No Africa
USA
2,000
1,000
0
1995 1996 1997 1998 1999 2000 2001 2002 2003 ECFMG
Interest in the US Among Foreign Medical Students
Survey of Medical Students
at
Bangalore-Ramiah Medical College
and
Bangalore Medical College
INDIA
Raghu Rao and Richard Cooper
2004
Preliminary data analysis
Survey of Indian Medical Students
% Male and Female
% Married
Prefer family values in India
More optimistic about India
US immigration laws difficult
Male
US less welcoming since 9/11
CSA too expensive Female
ECFMG exam hinders entry
Worth leaving India for US
Rao and Cooper, 2004 0 20 40 60 80 100
%
Survey of Indian Medical Students
Thought about training
outside of India
US
UK
Male
Canada, Australia, NZ
Other Female
Would remain away,
% outside India
Would remain in US,
% in US
Would remain in UK,
% in UK
0 10 20 30 40 50 60 70 80
Rao and Cooper, 2004
%
Survey of Indian Medical Students
Thought about training outside of India
Would remain after training
.
Thought about training in US, 1998
Thought about training in US, 2004
Would remain in US
.
Thought about training in UK
Would remain in UK
.
Thought about Canada, Australia, NZ
Thought about training in other
0 10 20 30
Rao, 1998 Academic Psychiatry % 40 50 60 70
Rao and Cooper, 2004
International Market for Medical Doctors
National Primary Care Research and Development Center
Manchester Center for Healthcare Management
Manchester, England
2003
• A wide range of “demander countries” is looking to source a
substantial proportion of their medical labour supply from
outside their own health systems.
• The hegemonic position of the USA was perceived as
unassailable.
Staying After Residency
AFTER RESIDENCY: J1 and H1b Visas
J1 Visa Waiver of 2-year return requirement (4,798 waivers)
Primary care or general psych in underserved area-three years
State Conrad-30 Program --- up to 30 waivers per state
Delta Regional Commission --- 8 states, 240 counties
Appalachian Regional Authority ~250 counties
Veterans Administration, HHS --- few
Pending Bills: J1 waivers for specialists in hospitals serving underserved
Redistribution of unused waivers ---1,500 available, 1200 used
H1b Visas
Program expired Sept. 30, 2003: 195K 65K visas
Exemptions:
Conrad 30 waivers of J1 visa requirements while in waiver
Residents in a “university
Sponsorship by nonprofit, university or government
Opportunities to Remain without an H1b visa
National interest waiver
Tourist visa
Extension of J1 to take exam
Small business (Canadians) under NAFTA
Bill pending to exempt former J1 visa holders from H1b cap
CONCLUSIONS
• The number of IMGs has varied with changes in
immigration policy, reimbursement policy and
exam-certification, but the trend has been upward.
• Half of all IMGs are from South Asia, North Africa and
the Middle East, where visa problems are the greatest.
• Foreign medical students are encountering
increasing difficulty in accessing the US system,
greater demand from the UK and Canada,
more obstacles to remaining in the US after training,
and better opportunities at home.
Thank you.
Entering IMG Residents 1995-2002,
% of GRADUATES in HOME COUNTRY
7%
6%
.
5%
% of Graduates
4%
3%
2%
1%
0%
U
a
ltic
ca
ia
ia
ica
r ic
/E
As
As
ri
Ba
er
n
Af
Af
Ca
Am
h
st
U/
/N
n
ut
Ea
ra
Z/
FS
So
st
tin
ha
/N
Ea
La
Au
a
id
bS
M
Su
Adapted from ECFMG and Eckhert, 2002
Survey of Indian Medical Students
% Male and Female
% Married Total
Prefer family values in India
Male
More optimistic about India
Female
US immigration laws difficult
US less welcoming since 9/11
CSA too expensive
ECFMG exam hinders entry
Worth leaving India for US
Thought about training outside of India
US
UK
Canada, Australia, NZ
Other
Rao and Cooper, 2004 0 20 40 60 80 100
%
Survey of Indian Medical Students
% Male and Female
Thought about training
outside of India
US
UK Total
Male
Canada, Australia, NZ
Female
Other
Would remain away,
% outside India
Would remain in US,
% in US
Would remain in UK,
% in UK
Rao and Cooper, 2004 0 10 20 30 40 50 60 70 80
%
Survey of Indian Medical Students
% Male and Female
Thought about training
outside of India
US
UK Total
Male
Canada, Australia, NZ
Female
Other
Would remain away,
% outside India
Would remain in US,
% in US
Would remain in UK,
% in UK
Rao and Cooper, 2004 0 10 20 30 40 50 60 70 80
%
Survey of Indian Medical Students
% Male
Prefer family values in India
More optimistic about India
US immigration laws difficult
US less welcoming since 9/11
CSA too expensive
ECFMG exam hinders entry
Worth leaving India for US
Thought about training outside of India
US
UK
Canada, Australia, NZ
Other
Would remain away, % outside India
Would remain in the US, % in US
Would remain un UK, % in UK
Rao and Cooper, 2004 0 20 40 60 80 100
%
Survey of Indian Medical Students
Thought about training outside of India
Would remain after training
.
Thought about training in US Total
Would remain in US Male
. Female
Thought about training in UK
Would remain in UK
.
Thought about Canada, Australia, NZ
Thought about training in other
Rao and Cooper, 2004 0 10 20 30
% 40 50 60 70 80
Survey of Indian Medical Students
Thought about training outside of India
Would remain after training
.
Thought about training in US
Would remain in US
.
Thought about training in UK
Would remain in UK
.
Thought about Canada, Australia, NZ
Thought about training in other
Rao and Cooper, 2004 0 10 20 30 40 50 60 70
%
IMG CHALLENGES
Concerns
US-IMGs vs. Foreign IMGs
Quality of educational programs
Rate of disciplinary actions
Hurdles
USMLE Steps 1, 2, 3
Clinical Skills Assessment (CSA) (cost, time)
Visas to take CSA exam
Visas to enter for residency
Decreased availability of H1b visas
(195K in 2003 65K in 2004)
Competition
England
Canada
Attractiveness of native countries
ECFMG Certificates 1993-2002
3000
South Asia
2500
East Asia
2000
Mid-East, No Africa
1500 Australia, NZ, Canada,
WEurope, Israel
1000 FSU/Baltic
500 Latin America
Sub-Saharan Africa
0
1992 1994 1996 1998 2000 2002
ECFMG CERTIFICATES
1995-2002
4,000
So Asia, Mid
East, No Africa
3,000 Europe, Canada,
Aus/NZ, Is, Africa
East Asia
2,000
Latin America
1,000
USA
0
1995 1996 1997 1998 1999 2000 2001 2002 2003
RESIDENTS
1995-2002
4,000
So Asia, Mid
East, No Africa
3,000 East Asia
Europe, Canada,
2,000 Aus/NZ, Is, Africa
Latin America
1,000
USA
0
1995 1996 1997 1998 1999 2000 2001 2002 2003
PERCENT of IMGs from before 1997
who are CURRENTLY ACTIVE in the AMA MASTERFILE
100
% of Certificate Holders .
75
50
25
0
y
ll
ia
a
SR
US
UK
s
t
a
n
yp
ra
an
in
ne
ta
re
d
e
Ch
In
Eg
US
kis
m
Ko
pi
Ov
r
ilip
Pa
Ge
Ph
IMGs
(all years)
Citizenship or Visa Status
12,000 Exchange visitors and
Temporary workers (H, J)
Permanent residents
9,000
IMGs
Native US
6,000
Naturalized US
3,000
Refugees
0
1985 1990 1995 2000
Year
Corrected for unknown
IMGs
(all years)
Visa Status
12,000
Exchange visitors and
Temporary workers (H, J)
9,000
IMGs
J-1, J-2
6,000 Exchange visitors
3,000
H-1, H-1b, H-2, H-3
Temporary workers
0
1985 1990 1995 2000
Year
Corrected for unknown
First Time PGY-1 Residents and ECFMG Certificates
25,000 Potential
IMGs 2,000
IMGs not matched
F-IMGs
20,000
US IMGs IMGs newly certified
DOs
Foreign IMGs
Physicians
15,000
US IMGs
10,000 Canadian seniors
DOs outside match
5,000 DOs in match
MDs outside match
0
MDs in match
PGY-1 Residents Applicants