Comparing United States versus International Medical School Graduate Physicians Who Serve African- American and White Elderly

The percentage of African-American physicians in the United States has remained constant over the last 30 years at 3.9 percent of all physicians, while the percentage of international medical school graduates (IMGs) providing medical care in the United States has increased dramatically over this same time-period (Mullan 1997; Association of American Medical Colleges 2000). In the early 1960s, IMGs in training and in practice entered the U.S. physician workforce at a rate of 10 percent; by 1995, IMGs consisted of approximately 25 percent of physicians in training or in practice in the U.S. An examination of the American Medical Association Masterfile reveals that during the period between 1981 and 2001, almost 125,000 IMGs entered the U.S. medical workforce (Mullan, Politzer, and Davis 1995; AMA 1996; Lohr, Vanselow, and Detmer 1996; Mullan 1996, 1997; Cooper 2003). North Carolina has experienced a similar influx of IMGs. Although physician immigrants are affected by the same push and pull factors that motivate international migration of the general population, some special circumstances affect them more intensively. Over the past 20 years there has been an increase in the number of IMGs entering and practicing in the United States due, in part, to the failure of U.S. medical school capacity to keep pace with the expanding graduate medical education sector. In the United States, every year there are at least 5,000 more openings for first year residency trainees than there are graduates of U.S. medical schools (Barzanzky and Etzel 2005; Brotherton, Rockey, and Etzel 2005). Many of these training slots filled by IMGs are in teaching hospitals in large urban areas that have traditionally served large numbers of minorities, uninsured, and low-income patients (Mullan, Politzer, and Davis 1995). Many IMGs who are foreign nationals come to the United States to obtain graduate medical education with the professed intention of returning to their home countries, and obtain J-1 Visas as a result (Mullan, Politzer, and Davis 1995; Mullan 1996). Despite the requirement that enjoins J-1 visa holders to return to their home country for at least 2 years upon completion of their education, it has been estimated that as many as 80 percent of these physicians actually stay in the United States (Mullan 1996; 2000). This is facilitated by a federally sponsored program that waives this “return” requirement for J-1 visa holders who agree to practice in designated rural or inner city physician shortage areas. Hence both the initial training location and the subsequent service locations of IMGs frequently put them in minority communities where other doctors are scarce. In its 1992 report, the Council on Graduate Medical Education (COGME 1992) concluded that IMGs positively affect access to health care in poor and rural underserved areas, as there is some evidence that IMGs practice in rural, underserved areas. In congruence with COGME (1992) Baer, Konrad, and Miller (1999) found almost 165 of fulltime equivalency physician staff positions in their sample of community health centers (CHCs)—private, nonprofit organizations chartered to provide primary care to poor and underserved populations—would likely be unfilled without IMGs. Further, Mullan (1997) states that many inner-city hospitals in the U.S. rely almost exclusively on IMGs to provide services to America's poor. The existing literature on IMGs, however, presents a muddled picture about IMGs in rural, underserved areas, with theories and countervailing theories, incomplete empirical evidence, and implications that “rural” and “underserved” have the same meaning. A comprehensive literature review by Mick and Pfahler (1995) and a subsequent study by Mullan, Politzer, and Davis (1995) found no conclusive work examining whether IMGs help remedy physician shortages in rural, underserved areas. Mick and Lee (1997) showed that IMGs do “fill gaps” for physician shortages, but the term “gap-filling” is difficult to define and can be interpreted numerous ways. The authors indicate that words like “under-service” and “gap-filling” have often been used loosely, based on anecdotal evidence, studied in limited ways, or linked without explanation to rural health care. As the medical care of poor and underserved African Americans is perhaps directly impacted by IMGs working in minority and underserved communities (Mick and Lee 1997) as well as in rural underserved than in rural nonunderserved areas (Baer et al. 1998), questions remain concerning the satisfaction with medical care and subsequent health care-seeking behavior that African Americans experience with IMGs. Patient satisfaction is an important indicator of medical outcomes (Auslander et al. 1997). Patient satisfaction has also been used to predict patient behavior patterns, because differences in satisfaction predict where patients choose to get treatment and the extent to which they comply with medical recommendations. Investigators have found that patients' satisfaction with their doctors and medical treatment have emerged as important determinants of patient commitment to and compliance with recommended treatment (Auslander et al. 1997). Our longitudinal, observational study will examine the impact that IMGs in comparison with U.S. medical school graduates (USMGs) have on the health care-seeking behaviors and satisfaction with medical care of a racially oversampled elderly urban and rural cohort of African Americans and whites. No study has examined longitudinally the impact that IMGs have had in comparison with USMGs on the health care-seeking behavior and satisfaction with medical care of the minority populations they serve.