International Medical Graduates and Global Migration of Physicians: Fairness, Equity, and Justice

In a prepared statement before the Senate Subcommittee on State, Foreign Operations and Related Programs, Laurie Garrett of the Council of Foreign Relations made the following comment on April 18, 2007: The world is desperately short of health professionals, and the severity of that gap promises to increase sharply in coming years….How are the United States and other wealthy nations filling that gap? By siphoning off doctors and nurses from the poor world. We are guilty of bolstering our healthcare systems by weakening those of poorer nations.[1] The debate on immigration has been dominant in this decade. The debate in the United States has often focused on workers from Latin America, with Mexico featuring prominently in the national psyche. One part of the immigration debate that has been noticeably missing is the role of highly skilled professionals, particularly physicians and nurses, who migrate from other countries to the United States for educational and professional opportunities. In this article, I wish to examine further the role of international medical graduates (IMGs) in American healthcare. I will specifically examine who IMGs are, why they migrate, and the ethical and justice implications of global migration of physicians from developing to developed countries. Part of my interest is personal. My parents are both immigrants and healthcare professionals: My father was a physician and my mother a nurse. They arrived in the mid-1960s at the time that Medicare was created, which has provided the financial subsidy for residency education in the United States. Like many immigrant healthcare professionals, they settled in smaller towns, places generally avoided by US medical graduates. The influx of IMGs like my father has generated some media interest in the role that immigrant healthcare professionals play.[2] Despite this interest, there is a paucity of articles on this topic in the bioethics literature. This is especially curious in light of the number of interesting issues with regard to cultural competence as well as healthcare access and distributive justice raised by IMGs. Who Are International Medical Graduates? Definitions are useful here. An IMG is a graduate from a medical school outside the United States; such a school is not accredited by the Liaison Committee on Medical Education. This committee accredits programs in the United States and Canada, leading to the medical degree.[3] According to Vijay Koli, past president of the American Association of Physicians of Indian Origin, there are different examples of IMGs in the United States. Most IMGs are foreign nationals who receive their medical degrees from schools outside of the United States or Canada. A smaller but significant number are US citizens who pursue their degrees outside the United States (eg, in one of the Caribbean medical schools). Yet another group comprises children of immigrants who wish to earn their medical degree in their parents' homeland (eg, India). Immigrant physicians must navigate through a morass of legal requirements to practice in the United States. They must be educated by a medical school that is recognized by the Educational Commission for Foreign Medical Graduates; they must pass the same licensing examinations as US-educated physicians; and they must complete a US residency. Despite this standardized approach to training, a not-so-subtle hierarchy exists in graduate medical education. As attested to by Abraham Verghese, there are “Plymouth Rock” training programs that favor US medical graduates.[4] These tend be the more prestigious programs affiliated with well-known academic health centers. Then there are “Ellis Island” programs that place a disproportionate number of IMGs. These programs are typically in inner-city teaching hospitals and are usually understaffed and thus have overworked housestaff. Critics have voiced their objections to relying so heavily on physicians trained elsewhere. As Fitzhugh Mullan noted, “We have no business using the medical schools of India and Pakistan and Romania and Canada to staff our needs. That's like 30 or 40 medical schools, full-out medical schools, graduating all of their classes into the United States. This is the brain-drain, and it's not necessary.”[5] Mullan's comment raises several important issues. First, should a rich, developed country such as the United States rely on international talent rather than cultivating its own set of skilled healthcare professionals? Moreover, should developing countries allow such highly skilled workers to benefit from a heavily subsidized education at home only to have these workers leave for better opportunities elsewhere? Lastly, what responsibilities do stakeholders have with regard to the migration of educated healthcare professionals, such as the agencies who recruit them, the hospitals that employ them, and the professionals themselves?