Initial Practice Locations of International Medical Graduates

During the 1960s and early 1970s, there was a consensus that a growing shortage of physicians would soon bring the U.S. health care system to a state of crisis (e.g., Ginzberg et al. 1981), and physician workforce policy welcomed International Medical Graduate (IMG) physicians into the United States. Between 1963 and 1970, the number of IMGs in the United States increased by 85 percent (Haug and Martin 1971). However, the favored status given to IMGs was short-lived. Responding to newly emerging fears of an impending physician surplus, Congress in 1976 passed legislation that restricted the ability of IMGs to remain in the United States after completion of graduate medical education (GME) (Eiler and Loft 1986). As a result, the inflow of new IMGs decreased in the late 1970s and remained stable throughout the 1980s. Between 1989 and 1994, however, the number of IMGs entering GME programs in the United States nearly doubled to about 25 percent (Council on Graduate Medical Education 1998). The sudden spurt in the number of new IMGs during the early 1990s refocused attention on the contribution of IMGs to the growth of the physician workforce. Motivated by concerns about an oversupply of physicians and the large government expenditures for GME, various policymaking organizations, including the Institute of Medicine (1996), the Pew Health Professions Commission (1995), and the Council on Graduate Medical Education (1998) have recently called for reductions in the number of IMGs in residency programs. The health policy research community is divided about the role of IMGs in the health care delivery system (e.g., Iglehart 1996). Many analysts believe that the entry of new IMGs exacerbates a nationwide oversupply of physicians (Politzer et al. 1998; Mullan et al. 1995), while others contend that IMGs are especially likely to locate in communities that are underserved by U.S. medical graduates (Mick and Lee 1997; Baer et al. 1998). Mick et al. (2000) examined these issues by comparing the geographical distribution of IMGs and U.S. medical graduates. They found that IMGs were more likely than U.S. graduates to practice in locales characterized as high in medical need or medically underserved, but many IMGs clustered in areas with an already abundant supply of physicians. They concluded that IMGs serve a significant “safety net” role, while simultaneously exacerbating physician surpluses. The existing research, however, has not directly examined the factors that affect IMGs’ choices of practice location. Numerous studies of the location choices of all new physicians have found that they are attracted to communities with affluent and well-educated populations, medical schools and residency training programs, mild climates, and low levels of health maintenance organization (HMO) penetration (e.g., Ernst and Yett 1985; Escarce et al. 1998). New physicians also tend to locate in communities with which they had prior contact, for example, during upbringing, medical school, or GME (e.g., Ernst and Yett 1985; Seifer et al. 1995). However, the location choices of IMGs are likely to differ from those of U.S. medical graduates. International medical graduates, especially those from foreign countries, may be more geographically mobile because they are less likely to be connected through family or friends to particular communities in the United States. Differences in state licensure requirements for IMGs, compared with U.S. graduates, may affect their practice location choices. Networks of established IMG physicians may play an important role in helping new IMGs to start their practices. Finally, many foreign-born IMGs, in particular, may have cultural and language differences that are more easily overcome in communities with large numbers of people of the same ethnicity. This article examines the initial practice location decisions of new IMG physicians who completed their GME between 1989 and 1994. Our study examines the extent to which new IMGs are attracted to market areas with large minority populations and whether this attraction varies with the physician's own ethnicity. We also examine whether new IMG physicians tend to choose practice locations close to where they received GME training, whether their location decisions are affected by state licensure requirements, and whether they are attracted to market areas with established IMGs.