Guest Column

In the debate over work force, IMGs remain a difficult issue

From the February 1998 ACP Observer, copyright © 1998 by the American College of Physicians.

Editor's note: Harold J. Fallon, MACP, Chair of ACP's Board of Regents, writes this month for CollegeWatch. The President's Column will return next month.

For the past decade, there have been dire predictions of an impending oversupply of physicians, especially subspecialists.

Internal medicine has been the focus of much of these predictions because so many internal medicine residents have historically gone on to subspecialty careers. Recently, specialty societies in cardiology, gastroenterology and pulmonary medicine have argued for reductions in their residency positions (medical oncology has proposed no change in training positions), resulting in a dramatic decline in fellows in some subspecialties.

Between 1992 and 1996, there was a drop in first-year fellows in cardiology (11%), pulmonology (18%), gastroenterology (26%) and rheumatology (35%). Only nephrology noted a small increase in the total number of fellows.

U.S. medical students seem to be responding to the perceived need for general internists. For the first time in many decades, more than half of all medical students entering internal medicine are choosing generalist careers.

Hopefully, this trend will lead more general internists to seek careers in underserved urban and rural areas of this country, where physician demand remains high. Federal initiatives such as the National Health Service Corps, as well as state and local programs, could also be invigorated to meet this need.

Despite early signs that medical students are beginning to embrace generalism, the physician work force remains a difficult issue. When the number of U.S. medical graduates dipped in the 1990s and students lost interest in general medicine in the late 1980s, training programs responded by increasing the number of international medical graduates (IMGs) working in the nation's teaching hospitals. Many hospitals still had clinical service needs, and Medicare's open-ended funding of residency programs made IMGs an attractive alternative to the reduced number of U.S. medical graduates.

Recent data suggest that there has been a significant decline in total residency positions in the United States, and that this has begun to reduce the number of positions filled by IMGs. This trend, along with overall reductions in residency slots, has helped to moderate the influx of physicians from abroad. However, the perceived excess of physicians has meant that the number of IMG trainees has become a hot issue in work force discussions.

Limits

Congress became more interested in physician work force issues, and the Balanced Budget Act of 1997 has dramatically altered hospital incentives to recruit and hire residents. These changes include the following:

• The number of funded residency positions is capped at the 1996 level for each hospital. There are some exceptions for rural hospitals.
• The indirect medical education (IME) allowance to teaching hospitals will be reduced over the next five years, substantially reducing GME funding to teaching hospitals.
• HCFA will study the widely discrepant costs of direct medical education (DME) throughout the United States. These costs to HCFA range from a low of about $15,000 per resident per year to more than $150,000 per resident in some hospitals. A report and recommendations are due next summer.
• The Medicare Payment Advisory Commission will report on the role of IMGs in residency training programs and in the U.S. physician work force. This is an especially sensitive issue for internal medicine, because nearly half of our residents in 1996 were IMGs.

Medical organizations such as the Institute of Medicine, the American Association of Medical Colleges and the AMA have addressed the physician work force issue by proposing restrictions on the number of physicians from other countries who are allowed to train and remain in the United States. The most common suggestion is that federally funded residencies not exceed 110% of the number of U.S. medical graduates, leaving approximately 1,500 slots per year for IMGs, whether they are U.S. or foreign nationals.

ACP's policy on physician work force supports reducing federally funded residencies to more closely align the number of new physicians with the anticipated needs of the U.S. population. While ACP's proposal would also bring the number of resident positions closer to the number of U.S. medical graduates, the College has not proposed any specific target numbers. (The full text of ACP's policy is available on ACP Online at www.acponline.org/hpp/pospaper/health.htm.)

The College also advocates continued training opportunities for IMGs who return to their home country as leaders in medicine, or for those who remain in the United States as research or academic physicians. While ACP has not taken a position on the exact number of residencies in this category, the impending congressional report may provide specific recommendations.

Although the United States is not the only western nation to admit foreign physicians for training, we allow more IMGs to stay and practice than most countries. It is important to point out that a significant number of the physicians who train in foreign medical schools are in fact U.S. citizens who return to this country for residency training. As a result, they may remain in this country after residency regardless of where they attended medical school.

Tension

A tension has arisen between the anticipated oversupply of physicians in the United States and the recruitment of physicians from abroad. If training programs are downsized, thus reducing the number of IMG positions, there could be reduced availability of medical care for patients in some urban communities. This problem will be most acute in internal medicine, which provides the bulk of inpatient services in many urban teaching hospitals.

Most IMGs in U.S. residencies are extremely well educated, pass the same examinations as U.S. medical graduates and have provided critical medical services by working in hospitals that care for the uninsured and indigent. The IMGs in this country have demonstrated excellence and dedication to enhancing the U.S. health care system and clearly are not to blame for any anticipated oversupply of physicians and they should not be held accountable.

IMGs must be accorded the same respect, opportunities and high regard as U.S. medical graduates. Our country and our profession is dedicated to pluralism and diversity, and we should separate the issues of future manpower policy from our obligations and respect for our colleagues in the profession, many of whom are fellow members of the College.

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