PEDIATRIC PERCEPTIONS

(1)

(Received March 9; revision accepted for publication July 3, 1970.)

ADDRESS FOR REPRINTS: Department of Pediatrics, University of Washington School of Medicine,

Seattle, \Vashington 98105.

PEDIATRICS, Vol. 46, No. 5, November 1970

PEDIATRIC

PERCEPTIONS

760

The

Education

of

Foreign

Medical

School

Graduates

Ralph J. Wedgwood, M.D.

Department of Pediatrics, Unicersily of Washington School of Medicine, Seattle, Washington

Tile pTi71Z43T UT/)OSC of inlcr:ahip and residency is education. Foreign interns and residents-generally not

(IS tee’!! lr(lillC(1-arC Tt’CTUite(l primarily for .sercicc. Thus it is the cery sick hos/)italized /)atie1it who is often

C(Ir(’(l for h,1 the J)OOTh/ traifl(’(l /)hysician. It is clear that American medicine cannot easily justif!, dual slandare!.s. )et (111(11st(Ifl(I(1r(Is exist.’

T

lIE trailling of graduates from foreign

medical schools presents a special

problem in medical education. Their

pr’s-ence in trainillg programs call I)e regarded

fronl two totally disparate points of view.

Tile first view, probably most generally

held, is that foreign medical graduates are

less well relarec1 for iiiternship and

resi-dencv than their American counterparts.

The (liffictiltieS iiiiposed by language 1)arri-cr5, by differences in education, social ctis-tolils, and values are a reality. From this

ersective the foreign medical graduate is

ilot as “desirable” a house officer as tile

graduate of au American medical school;

programs with a large proportion of foreign

medical graduates are considered less

com-l)etitive, or strong, than those with fewer.

Hospitals,

however,

Ileed house officers

to provide patient care services. Since the

(‘lid of \Vorld \Var II there have been far

more positions available than applicants. Hospitals compete strongly for these physi-cians, often. it must he a(lmitted, to utilize their services for patient cane rather than to j)rOvide them with an educational

opportu-nity. The national picture over the past 20

‘ears

(

Fig. 1

) shows

this steady trend. In

1968-1969, about one third of all house

of-ficers ill the United States were foreign

graduates; nearly 20% of available house

officer positions were unfilled. #{176}

0 The majority of the data presented was

ob-tItifle(l r calculated froni the education issue of tile

J.A.M.A., 210:1455, 1969.’

Thus, a different but equally valid

view-point, lllcreasingly voiced but not

fre-quently recognized, is that the foreign

mcd-ical graduate is a vital component of our

health manpower resources. The United

States is heavily dependent upon tile immi-gration of physicians to provide the health

services needed by the expanding

popula-tiOll. Each year about 1,600 new foreign physicians’ are licensed to practice; foreign

graduates thus constitute at least 15% of

the additional number of physicians

certi-fled for practice each year. The current

ilealth manpower crisis is considerably

ameliorated by this fact.

The physician manpower pool for

hospi-tals is even more heavily dependent upon

the foreign graduate. In 1968-1969, there

were over 50,000 individuals in graduate

training positions

(

internships, residencies, alld fellowships

)

in the United States; this constitutes more than 15% of all the

physi-cians in the nation. Of these, greater than

olle-tilird

(

18,500

)

were foreign graduates. \Vhile some

(

about 2,200

)

were American

or Canadian citizens trained abroad, the

vast nlajonity were foreign graduates of

for-eign 1)irth. The nations contributing the

largest numbers were tile Philippines

(

24%), India

(

13%) , and Korea (8%).

\Vithout these physicians many hospitals

and communities would be in serious

diffi-cultv. Foreign graduates provided over half

of the interns in Florida; over half of the

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40

RESIDENCIES

20

I0

5

YEAR

761

0

0 0

U)

z

0

I-U)

0

0. Ii.

0

w

z

Fic. 1. The numbers of internships and residencies, the numbers filled by

American versus foreign medical graduates, and the numbers of vacancies

by year 1952-1969 (adapted from J.A.M.A.2).

Island, and New Jersey; and oven half of

the residents in Delaware, West Virginia,

and Puerto Rico. The contribution of

for-eign graduates to the hospital system in the

United States is equivalent to the output of

perhaps 30 additional medical schools. The

dependency is enormous, and the

conse-quence of the elimination of this source of

physicians would be devastating.

Thus, probably between 4,500 and 6,000

physicians who are foreign graduates

com-plete their graduate training each year. Not all remain in the United States. Neverthe-less, a significant number do. Of the foreign

graduates who are foreign born, 28% enter

on a permanent visa. It can be estimated that at least 1,600 foreign graduates enter

practice in the United States each year.1

The contribution to the practicing

commu-nity constitutes the output of about 15

“average” medical schools in the United

States. In current economic terms, if these

foreign sources were eliminated, it would

be necessary to construct

and

equip these

15 additional new medical schools at a capi-tal cost of at least $750,000,000 to replace the deficit. It would also necessitate

addi-tional annual expenditures for medical

edu-cation of about $75,000,000

(

excluding

re-search expenditures

)

and the recruitment

of an additional 3,000 faculty from an

a!-ready depleted pooi. The immigration of

foreign medical graduates is therefore

highly advantageous to the United States,

both numerically and economically.

Gradu-ate training opportunities appear to be a

popular and effective mechanism for this

recruitment.

These facts are equally apparent in pedi-atrics.f In 1969, 35% (577/1,657) of physi-cians presenting for specialty board written

examinations and 20% of those passing the

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0 Rodiol.

80

OPed.

70

OOrtho. 0 Path.

Olnt. Med.

60 OOb./Gyn.

0 Psych.

0 Surgery

50

I I i I

0 10 20 30

PERCENT UNFILLED POSITIONS

IN AFFILIATED PROGRAM

Fic. 3. The lack of relationship between recruitment problems (percent

un-filled positions) and proportion of all foreign medical graduates in field

re-ceiving training in affiliated programs.

950 to 967

10 00

800

I-600

I-

4001-950 955 960 965 970

FIG. 2. Candidates presenting to the American

Board of Pediatrics for Written Examination,

1950-1967. ( I am indebted to the American Board of

Pediatrics for providing this information: data for

1968-1969 are not included as changes in the

exam-ination PrOcelIIre make the data noncomparable.) 762

z

>

0<

(00

I-(9J

ZL.

(LL.

-J -J <(9

z

u_

-oz z

0

Ui

a-FOREIGN MEDICAL SCHOOL GRADUATES

0 Anesth.

TOTAL oral examinations

(

145/749) were foreign

graduates. Indeed, virtually the entire

in-crease in the number of new pediatricians

certified by the specialty board over the

GRADUATES past 20 years can be accounted for by

for-eign graduates

(

Fig. 2) . Noteworthy is the

fact that these individuals have a

signifi-AMERICAN cantly higher failure rate

(

in 1969, 43% in

GRADUATES written and 35% in oral examinations

)

than

their American counterparts

(

4% in written

and 20% in oral examinations

)

, which

sug-gests, if the examinations reflect

educa-tional experience, that their training has not been equally satisfactory.

If foreign medical graduates are

incon-ponated in graduate training

(

intennships and residencies

)

solely to provide services

to hospitals that cannot obtain the

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TABLE I

INTERNSIIIPS, IN ALL FIELDS, BY PROGRAM AFFILi.&TI0N, HOSPITAL SIZE, AVERAGE NUSIBEIt OF PosITIoNS FILLED, PERCENT UNFILLED POSITIONS, PERCENT FOREIGN GRADUATES (ALL PER HOSPITAL),

AND SIZE OF PROGRAM Gaoup AS PERCENT OF ALL INTERNSHIPS

Fareign Graduate8 Programs as

Pro-Hospital Size, Average Nvmber Unfilled Positions in Filled portion of Total

Number of IJe4s Poxitions Filled (%) Poxitions

(%)

Number of Intern-ships (%)

Nonafflhiate4 Programs

<2OO 4.8 32 89 1.

WO-299 6.8 34 78 6.3

300-499 8.0 38 64 14.’2

>500 1L8 31 41 8.’2

Comhined”* F2.9 40 6l 1.7

Total 8.5 35 6 31.6

Affiliafed Programs

<2oo 4.3 31 3 0.9

OO-299 8.1 29 31 4.2

300-499 12.Z 6 ‘24 18.1

>500 t4.7 16 14 38.i

“Combined”4 ‘20.3 18 8 7.0

Total 16.6 20 17 68.4

All Programs

Grandtotai H.7 26 ‘31 100.0

Adapted from J.A.M.A., 210 : 1494, 1969.

* Combinations of more than one hospital or ilistitutiorl.

appropriate

(

even if not desirable) that

they should obtain positions in weaker

pro-grams, recognizing frankly that the purpose

of their role is service, not graduate

train-ing, and reserving the stronger programs in

consequence as educational opportunities for American graduates.

On the other hand, if, as it appears, the

foreign medical graduate is an increasingly

important component of physician

man-power in the United States and if his prior education experience has not been sufficient

to meet our usual standards, should he not

receive better graduate training

opportuni-ties so as to upgrade his capability? To

meet both manpower requirements and

standards, should not his graduate training

be better matched both to his background

and

our national needs? If graduate

train-ing is a good nlechanism for both

recruit-ment and instruction, should not the

intern-ships and residencies offered to these

foreign students be viewed from their

func-tion as education, rather than as simple

ac-quisition of hands to provide services?

Should not institutions better able to provide

good graduate education assume more of

tlliS important responsibility?

Nationally, considering all internships

and residencies, the proportion of foreign

graduates in a program varies considerably

with the affiliation of the program with a

medical school and the hospital size. In

in-ternship

(

Table I

)

nonaffihiated programs

have almost four times the proportion of

foreign graduates as those programs which

are affiliated with a medical school. The

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resi-764 FOREIGN MEDICAL SCHOOL GRADUATES

TABLE II

RESIDENCIES IN ALL FIELDS, NATIONALLY, BY PROGRAM AFFILIATION, SIZE OF hOSPITAL, NUMBER OF POSITIoNS FIIIED, PERCENT UNFILLED, PERCENT FOREIGN GRADUATES (ALL PER HOSIITAL), AND SIZE

OF PROGRAM GROUP AS PERCENT OF ALi RESIDENCIES

llospital Size, Average Number Unfille4 Positions

.‘Vumber of Beds Positions Filled (%)

Foreign Graduates

in Filled

Positions

(e

‘IC

Programs ax Pro-portion of Total Number of

Ilesi-dencies

((

“%Oflaffihiated Programs

<2()() 3.2 36 .59 1.1

‘2()O-t9I) 5 . 7 Z7 66 . ‘2

31)0-499 9 .7 30 66 6.0

>500 18.7 24 5’2 8.3

(oInbiIIed* 13.6 ‘23 37 3.0

‘l’otal 10.3 27 .56 ‘20.6

Affiliated Programs

Calculated from J.A.M.A., 210: 1494 and 150’2, 1969.2

<t00 .5.6 20 17 1.8

00-99 9.9 ‘20 39 2.3

300-499 21.3 1 ‘34 11.9

>500 49.7 14 27 32.6

“Conibined”4 76.3 11 21 30.8

Total 36.7 15 26 79.4

All Programs

Grand total 14.0 17 3t 100.0

Adapted from J.A.M.A., 21O:1502, 1969.2

* Combinations of more than one hospital or institution.

dencies

(

Table II

)

where the difference is

twofold. Nonaffiliated programs also have

a greater proportion of unfilled

positions-almost twofold-than affiliated programs.

Both in internship and residency programs,

the smaller institutions have a higher

pro-TABLE III

TIlE PROPORTIONAL DIsTIuBurIoN OF AMERICAN AND FOREIGN MEDICAl, GRADUATE STUDENTS IN SMALL

ITOSPITALM AND NON-AFFILIATED PROGRAMS

Small hospitals Nonaffihiated Graduate Students

(<300 beds) Programs

Percent of all American 6 14

Percent of all foreign 13 4

portion of foreign graduates than the larger

(

with one exception-affiliated residencies

in hospitals with less than 200 beds

)

.

Fi-nally, usually, although not uniformly,

smaller institutions have a greater propon-tion of unfilled positions.

Therefore, it is clear that foreign gradu-ates are generally congregated

proportion-ately in nonaffihiated, smaller programs

which appear to have difficulty in attracting

house officers. In 1968-1969, 42% of all

foreign graduates

(

about 6,000 individuals)

were in nonaffiliated programs. One out of

every eight foreign graduates

(

nearly 2,000 individuals

)

were in smaller hospitals

(

<

300 beds ). This distribution contrasts

sharply with the opportunities for American

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TABLE IV

PEDIATRIC INTERNSHIPS AND RESIDENCIES,*

ALL PER PROGRAM

. . Nonaffiliated

Poszt ion

Programs

Affiliated

Program.,

Internships

Average number of positions

filled 1.2

Proportion of all internship

positions filled 3 .5

Unfilled positions ((j) 40

Foreign graduates (%) 38

4.5

96.5

16

10

Residencies

Average number of positions

filled 4.5

Proportion of all residency

positions filled 17 .6

Infilled positions (‘h) 19

Foreign graduates (%) 68

10.1

8’2 .4

13

37

Adapted from JIMA., 210:1491 and 1499, 1969.’

* Excluding subspecialty programs.

TABLE V

TIlE ASSUMPTION OF RESPONSIBILITY IN AFFILIATED

PROGRAMS FOR TIlE EDUCATION OF FOREIGN MEDICAL

GRADUATES-IHE PROPORTION OF ALL FOREIGN GRADUATES IN FIELD, RECEIVING THEIR TRAINING

IN AN AFFILIATED INTERNSHIP OR RESIDENCY PnoGuAI, GIVING RELATIVE SIZE OF EACH FIELD

Field

Projx’rtion of Foreign

Medical Graduates

(%) in Field, in Affiliated Programs

Field Size as Percent of

Total Number of Residents

in Training

Interns4 Residents

Anesthesiology - 83 4.3

Internal nieolicine 4.5 63 17.7

Obstetrics and

gynecology 4’2 60 7.’2

Ortilopedics - 66 5.0

Pathology 74 66 6.4

Pediatrics 61 74 6.3

Psychiatry - .57 10.4

Radiology - 81 6.4

Surgery 46 5’2 17.5

Ailfiekis 38 64 100.0

Adapted from J.A.M.A., 210: 1491 and 1499, 1969.2

* Combining “straight” and “rotating” internships

with special emphasis. ARTICLES

foreign graduates in small hospitals is two

times, and in nonaffihiated programs three

times, that of their American counterparts. If it is true that the smaller institutions or

programs and the nonaffiliated programs

are “weaker,” it would appear that the

edu-cation of the foreign medical graduate has

been left by default to those least able to

cope with the problem. If it is true that the foreign graduate requires better education

to “upgrade” his knowledge and bring him up to standards, the allocation of resources

for graduate education seems reversed-the

group needing the most gets the least.

Although equally detailed information is

not available for pediatric training, the

same trends

(

summarized in Table IV

)

ex-ist. Nonaffihiated programs have nearly four

times the proportion of foreign graduates in

pediatric internship and almost twice the

percentage in pediatric residency as have

affiliated or medical school programs. The

same relationship to recruitment is

appar-ent. Nonaffiliated programs have higher

va-cancy rates. Thus, while the medical school

pediatric departments have assumed

re-sponsibility for most of the graduate

stu-dents in the field

(

97% of internship and

82% of residency positions

),

they have not

assumed equivalent responsibility for the

training of foreign medical graduates,

phys-icians who represent an increasingly large

proportion of the new pediatricians for the

nation.

However, this criticism should be

consid-ered in relation to the assumption of this type of responsibility by other clinical

de-partments in medical schools. The

informa-tion for the nine largest specialty training fields is summarized in Table V. Pediatric

departments, through the affiliated

pro-grams, have taken under their aegis 61% of

all foreign medical graduates taking pediat-nc internships and 74% of the foreign grad-uates in pediatric residency training. This is

a far higher proportion than the national

average. No other fields, except pathology

in internships and anesthesiology and

diology in residency, have accepted an

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766 FOREIGN MEDICAL SCHOOL GRADUATES

Because one easy

(

and disturbing

)

inter-pretation of these data is that the fields

which have assumed the greater

responsi-bility for foreign graduates are those with

the greatest recruitment problems, the aver-age rate of unfilled residency positions, and average proportion of all foreign graduates in affiliated programs is displayed by field in Figure 3. There is no close relationship. Tile proportion of unfilled positions in, for

example, pediatrics, internal medicine,

radi-ology, and obstetrics are not dissimilar, yet the proportion of responsibility for all

for-eign graduates varies from 60 to 80%.

An equally valid

(

and more appealing) interpretation is that pediatric departments,

perhaps unintentionally, have accepted the

importance of training of foreign medical

graduates for our health manpower crisis

and have assumed the responsibility to a

larger degree than other fields.

Assumption of nesponsil)ility for the

addi-tional foreign medical graduates in nonaffi-hated programs would he a more attractive

proposition if the importance of such

ne-cruitment was recognized nationally and if

sufficient funds and resources were made

available to the departments and hospitals

for modifications of their programs-for

ex-ample in language training-to match the

special needs of this particular group of

stu-dents. Present federally funded programs

preclude the development of special

train-ing for significant numbers of these foreign

physicians who could help solve, at least in

part. the current health care crisis.

The arguments presented neglect the

mon-al and political problems posed by the

ne-cruitment of physicians from other nations.

Through this “brain drain” the United

States is undoubtedly depriving developing

nations of badly needed professionals and is

creating an additional economic and

educa-tional burden on already limited resources.

Yet, the trend of migration appears to be

established and continuing. Therefore, it is

at least appropriate to consider those

changes in our programs which might

in-crease the effectiveness of our training for

this large group of physicians. Foreign

graduates who come to the United States

for training should be provided with

im-proved educational opportunities so that

those who stay will contribute better to our

health services and those who return to

their countries of origin will have been

better educated for their own nations’

needs.

REFERENCES

1. Fein, R. : The Doctor Shortage. An Economic

Diagnosis. Washington, D.C. : The Brookings

Institution, 1967.

2. Medical Education in the United States.

J.A.M.A., 210:1455, 1969.

Acknowledgment

I am indebted to the John and Mary Markle

Foundation and the Commonwealth Fund for

grants which in part assisted in the preparation of

this paper. I am also indebted to Drs. Robert j.

Haggerty, Robert B. Lawson, Clement A. Smith,

and William B. \Veil for their many helpflll

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1970;46;760

Pediatrics

Ralph J. Wedgwood