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Applying For American Citizen

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									                                                                              Background
 The Application Pathways of
                                                                 Perception: US citizens who
American Citizens who Pursue                                     attend medical school abroad
                                                                 applied to, and were not
   Medical Careers Abroad                                        accepted to, US schools
                                                                 International Medical
                                                                 Graduates (IMGs) make up
         Amy Opalek & John R. Boulet                             25% of US physician workforce
   Foundation for Advancement of International
        Medical Education and Research                           Recent increases in numbers of
                                                                 US citizen IMGs registering
                                                                 with ECFMG
                     Presented at the                            Expansion of capacity in
    2008 AAMC Physician Workforce Research Conference            Caribbean medical schools
              2 May 2008, Crystal City, VA

                                                    FAIMER®                                               FAIMER®




        ECFMG Certification                                                       Purpose
Eligibility for ECFMG Certification
  Graduate from an international medical school listed in IMED
                                                                 To describe the application pathways
  (non-LCME school located outside the US or Canada)             of US citizen international medical
     Acceptable graduation year
     4 credit (academic) years                                   graduates (USIMGs)
  Pass a series of examinations: USMLE™ Step 1, Step 2 CK,
  Step 2 CS
  Primary source verification of medical education credentials      USIMGs – ECFMG “registrants” who
                                                                    indicated that they were US citizens at
Must be ECFMG-certified to:
  Enter accredited US residency and fellowship programs
                                                                    the time of matriculation
  Apply to take USMLE Step 3

ECFMG collects demographic data on all applicants

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               Data Sources                                                      Analyses
 Application data from AAMC & AACOM                              AAMC/AACOM application data merged
   1981-2006 applications                                        with ECFMG USIMG records
 ECFMG registration (application) data                              Matriculation trends over time
 for US citizen IMGs                                                summarized
   1987-2006 application cohort                                     Characteristics of USIMGs who do, and do
                                                                    not, make applications to US medical
      Application year = year of first examination
      attempted for ECFMG certification                             schools examined
                                                                      Focus on individuals who attended medical
   1985-2004 matriculant cohort
                                                                      schools in the Caribbean, the largest and
      Matriculation year = initial application year                   fastest growing regional group of USIMGs
      minus 2

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                                                                                                                    1
                          US Citizens Entering International                                                                                                                                           USIMG Characteristics
                            Medical Schools, 1985-2004                                                                                                                                                                            n=32,812
                                                                                                                                                                                    Region of Medical School
3000




2500                                                                                                                                                                                      58% Caribbean (n=18,900)
                                                                                                                                                                                          13% Central America (n=4,304)
2000
                                                                                                                                                                                          5% Western Asia (n=1,707)
1500
                                                                                                                                                                                          5% South-Central Asia (n=1,665)
                                                                                                                                                                                    Country of Medical School
1000
                                                                                                                                                                                          16%              Dominica (n=5,314)
                                                                                                                                                                                          16%              Grenada (n=5,084)
500

                                                                                                                                                                                          12%              Netherlands Antilles (n=3,775)
  0                                                                                                                                                                                       11%              Mexico (n=3,723)
           1985    1986   1987   1988   1989   1990   1991    1992   1993     1994    1995   1996   1997    1998    1999    2000    2001    2002     2003     2004
                                                                         Matriculation Year
             Source: ECFMG/AAMC/AACOM                                                                                               FAIMER®                                         Source: ECFMG/AAMC/AACOM                                                                              FAIMER®




                                  USIMG Characteristics                                                                                                                                             2004 Matriculation Year
                                                               n=32,812                                                                                                                         USIMGs' Country of Medical School
                                                                                                                                                                              600




             Native Language                                                                                                                                                  500


                     69% English (n=22,619)
                     30% Not English (n=10,043)                                                                                                                               400




                     1% Unknown (n=86)                                                                                                                                        300


             Gender
                     37% Female (n=12,058)
                                                                                                                                                                              200




             Age                                                                                                                                                              100



                     mean age at matriculation = 26.8
                                                                                                                                                                               0
                                                                                                                                                                                        Other     Israel   St. Kitts &   Poland   Dominican   Antigua &   Mexico   Cayman      Neth.     Grenada   Dominica
                                                                                                                                                                                                              Nevis                 Rep.       Barbuda             Islands    Antilles

             Source: ECFMG/AAMC/AACOM                                                                                               FAIMER®                                         Source: ECFMG/AAMC/AACOM                                                                              FAIMER®




                  USIMGs with and without Applications to                                                                                                                      USIMGs who Applied to US Medical Schools
                      US Medical Schools, 1985-2004                                                                                                                                    (MD or DO), 1985-2004
                                                             US Application          No US Application                                                                                                                   N with US Application        % with US Application

 1800
                                                                                                                                                                              1400                                                                                                                      100

 1600                                                                                                                                                                                                                                                                                                   90
                                                                                                                                                                              1200
 1400
                                                                                                                                                                                                                                                                                                        80

                                                                                                                                                                              1000                                                                                                                      70
 1200

                                                                                                                                                                                                                                                                                                        60
                                                                                                                                                                               800
                                                                                                                                                                     Number




                                                                                                                                                                                                                                                                                                              Percent




 1000
                                                                                                                                                                                                                                                                                                        50
  800                                                                                                                                                                          600
                                                                                                                                                                                                                                                                                                        40

  600
                                                                                                                                                                               400                                                                                                                      30

  400                                                                                                                                                                                                                                                                                                   20
                                                                                                                                                                               200
                                                                                                                                                                                                                                                                                                        10
  200

                                                                                                                                                                                    0                                                                                                                   0
       0
                                                                                                                                                                                        1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004
            1985   1986   1987   1988   1989   1990   1991    1992   1993     1994   1995    1996   1997   1998    1999    2000    2001    2002    2003     2004
                                                                        Matriculation Year                                                                                                                                           Matriculation Year
             Source: ECFMG/AAMC/AACOM                                                                                               FAIMER®                                         Source: ECFMG/AAMC/AACOM                                                                              FAIMER®




                                                                                                                                                                                                                                                                                                                        2
                             Caribbean USIMGs with and without                                                                                                                        Non-Caribbean USIMGs with and without
                                      US Applications                                                                                                                                            US Applications
                                                          Applied to US School     Did Not Apply to US School                                                                                                                 Applied to US School        Did Not Apply to US School

1200                                                                                                                                                                    800



                                                                                                                                                                        700
1000


                                                                                                                                                                        600

 800
                                                                                                                                                                        500



 600                                                                                                                                                                    400



                                                                                                                                                                        300
 400


                                                                                                                                                                        200

 200
                                                                                                                                                                        100



  0                                                                                                                                                                       0
            1985    1986     1987   1988   1989    1990   1991   1992   1993     1994   1995      1996   1997   1998   1999    2000      2001    2002   2003   2004            1985    1986     1987   1988   1989    1990   1991   1992   1993    1994   1995   1996   1997   1998    1999   2000   2001   2002   2003   2004
                                                                           Matriculation Year                                                                                                                                                 Matriculation Year

               Source: ECFMG/AAMC/AACOM                                                                                                   FAIMER®                                 Source: ECFMG/AAMC/AACOM                                                                                           FAIMER®




               Country of Medical School for USIMGs who                                                                                                                          Country of Medical School for USIMGs who
                 did Apply to a US School, 1985-2004                                                                                                                             did not Apply to a US School, 1985-2004
             Grenada                                                                                                                                                           Dominica



            Dominica                                                                                                                                                             Mexico



   Neth. Antilles                                                                                                                                                       Dominican Rep.



              Mexico                                                                                                                                                      Neth. Antilles



                Israel                                                                                                                                                              India



           Philippines                                                                                                                                                        Philippines



               Ireland                                                                                                                                                          Grenada



 Cayman Islands                                                                                                                                                         Cayman Islands



 Dominican Rep.                                                                                                                                                                 Pakistan



       Saint Lucia                                                                                                                                                                Poland


                         0          500           1000        1500         2000          2500            3000          3500           4000          4500         5000                       0                        500                    1000                        1500                     2000                      2500

               Source: ECFMG/AAMC/AACOM                                                                                                   FAIMER®                                 Source: ECFMG/AAMC/AACOM                                                                                           FAIMER®




  Country of Medical School for USIMGs who did
        and did not Apply to US Schools                                                                                                                                                                                      Discussion
                                                                                                                                                                                   Many USIMGs do not make US medical
                                                                  US Application         No US Application

 6000

                                                                                                                                                                                   school applications
 5000                                                                                                                                                                                       Overall, many US citizens bypass the US medical
                                                                                                                                                                                            school system
 4000                                                                                                                                                                                       Majority of recent Caribbean matriculants do
                                                                                                                                                                                            apply to US schools (MD or DO)
 3000                                                                                                                                                                                       Majority of recent non-Caribbean matriculants
                                                                                                                                                                                            do not apply to US schools
 2000
                                                                                                                                                                                   As US medical schools expand, will these
                                                                                                                                                                                   individuals apply to these programs?
 1000
                                                                                                                                                                                                  Acceptance? Quality?

       0
                                                                                                                                                                                   More US citizen IMGs = less diversity
              Saint Lucia     Dominican      Cayman           Ireland     Philippines          Israel       Mexico      Neth. Antilles       Dominica      Grenada
                                Rep.         Islands

               Source: ECFMG/AAMC/AACOM                                                                                                   FAIMER®                                                                                                                                                    FAIMER®




                                                                                                                                                                                                                                                                                                                                  3
Limitations/Future Studies
Limitations
  Definition of matriculation year may introduce
  some errors
  Only have data on American citizens who apply
  through ECFMG
Future Studies
  Detailed analysis of MD/DO applications of
  USIMGs (timing of applications, etc.)
  Investigate factors associated with US/no US
  application
    USMLE performance of USIMGs
    Medical school characteristics

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