Heidi Chumley, MD
This year, the American Academy of Family Physicians’ report on the ACGME Family Medicine Match goes further than any of its previous 34 editions by acknowledging the existence of international medical schools, which collectively are a major contributor to the primary care workforce of the United States.
How big is the contribution? The report doesn’t tell us, though its purpose, according to its authors, is to help medical schools understand how well they are doing their part in contributing to the primary care workforce and guide strategies for further development. There is much to learn from international medical schools, particularly those that primarily educate and train students originating from the US to return to it for residency and practice.
International medical schools provide the ballast for a primary care workforce that desperately needs it. This year, Ross University School of Medicine, St. George’s University School of Medicine, and American University of the Caribbean School of Medicine (where I serve as executive dean) accounted for about 15% of all new family medicine residents in the United States. That’s not a passing comment in the US family medicine workforce story—that’s a major theme. And it’s a consistent theme: about 30% of the graduates in AUC’s history are practicing in family medicine.
International schools vary in size, and among the three mentioned above, AUC is the smallest. In 2015, 62 (28%) of our graduates entered family medicine residencies, a higher number and percentage than any US allopathic school reviewed in the report. For perspective, the 13 public and private schools in New York had 83, the six University of California system schools totaled 75, the four University of Texas schools had 70, and all seven medical schools in Florida combined for only 44.
Meanwhile family medicine advocates continue to worry over how to get more students into US medical schools instead of supporting the international schools that continue to produce family physicians. Two very powerful myths cloud the discussion about family medicine as a discipline and schools like mine as a separate issue. The first myth is the outdated notion that a US allopathic graduate is somehow better than an IMG. The second myth is actually a fantasy: the idea that US MD schools will somehow get better at producing family physicians. The evidence just doesn’t bear that out.
We all know of remarkable initiatives underway at some schools, but consider the US MD institution (AAMC, LCME, etc) as a whole. If there was real concern about family physicians, at a minimum new medical schools would be required to produce them, but it’s not happening. Last year the newer medical schools contributed very few family physicians. University of Central Florida, Florida Atlantic University, and Florida International University combined for only seven family medicine residents. Oakland in Michigan had just two, Texas Tech University Paul L. Foster five, and Virginia Tech Carillon three—while Hofstra had none. The best result I see is USC-Greenville notching six family medicine residents, which puts them at 8.5% and therefore at least close to the US average of 8.7%.
Schools like AUC want to be part of the solution when it comes to creating and nurturing a family medicine workforce that meets the country’s needs. Given that commitment and the desire of the vast majority of our students and graduates to practice in the US, there are numerous actions the family medicine community can take to support our participation and continued contribution:
- Host sessions at your major educational meetings to increase the awareness of and understanding of international medical schools.
- Allow medical students at international schools to be regular student members of your organizations. If you can’t go that far, at least allow US citizens attending international medical schools to join as regular student members.
- Voice opposition to the practice of residency programs using percentage of US MD graduates who are residents as a quality measure.
- Ask hard questions about social accountability of family medicine residency programs who will not consider international graduates who came from the underserved parts of their states and plan to return there to practice.
- Encourage and support studies that look not only at the attributes of US allopathic schools but also at the attributes of international medical schools associated with higher percentages of graduates choosing family medicine.
- Advocate for all loan repayment programs to extend eligibility to international graduates.
- Help educate family physicians in your pre-med mentorships and shadowing programs to encourage students who are not admitted to US medical schools to consider an international school with a proven track record in producing family physicians.
There is much work to do to ensure that the US has an adequate supply of family physicians to make progress on the triple aim. It is time to be working together.
STFM Blog 
Thank you for a thought-provoking article. You say that the first myth is the “notion that a US allopathic graduate is somehow better than an IMG.” Although I could guess at some possible reasons, can you explain your reasoning for why this is a myth?
This is an important discussion to have and the meager increase in US graduates going into family medicine is a problem that is not likely to go away in the forseeable future. The payment reforms from CMS, now open to question with Republican admininstration, have some potential to change things but will take decades to implement.
“New” US schools often are private, incur lots of student debt, and so it is not surprising that their graduates choose high salaried specialties. What Dr. Chumley describes however is certainly not the solution, but a contribution that needs to be explored. Over 50% of entering family medicine residents have been non-US grads for over a decade and there are at least two questions that need to be examined in that regard: how do US grad/IMG grads – and not just from the heavily US citizen schools she discusses – compare during residency programs and secondly, what it the career trajectory of the two groups. STFM has give some attention to the cultural and organizational adjustment that physicians who come to the US for training have to make. But studies of short and long term effects of IMG residents and graduates would give a better picture of the contributions – and the value added from cultural and socioeconomic diversity that isn’t present in US medical student – of IMG to the family medicine workforce.
Finally, it would be good to see more visibility of IMG graduates as part of STFM so we can have these necessary conversations in helpful and constructive ways.
No source of primary care, school, or training model can address deficits of generalists and general specialties as long as the financial limitations remain with too little revenue plus costs of delivery and complexity increased by design. The concepts of Triple Threat are not the problem. The crude, costly, distracting methods are the problem.
Half of Americans live where primary care is half enough in places where disparities in health spending contribute to disparities in access and in outcomes.
Expansions of NP, PA, Caribbean, and Osteopathic annual graduates at 6 to 12 times the annual population growth rate (about 0.75%) for decades and since 2002 for US MD have not resolved deficits in generalists, general specialties, rural America, or 2621 counties lowest in primary care and other health care workforce with 40% of the US population. In fact the innovation, digitalization, certification, and regulation focus of the past decade has reduced the primary care investment from 38 billion in these counties to 30 billion. This is the wrong direction stimulated by Triple Aim implementation. HITECH to MACRA to PCMH costing over $50,000 per year per primary care physician per year for each and with higher costs of turnover by over $50,000 a year.
The strong foundation that the US health system must have is insufficient and ineffective due to the financial design.
Even worse, our role as academic physicians is to be truthful and honest to our graduates – especially any that we influence to do primary care careers or careers where most needed. Unless we fix the financial design, our lies are not much different than lies by deans, institutions, programs, or associations.
We don’t need another program or school or type of training. We need one nation supporting the half of the nation most behind – and supporting those who provide health care for this half of the nation left behind with half enough.
My daughter, Dr. Faith Dillard spent more residency hours than most and has done a great job at George Washington Medical School and now with her job in the ER. She is a great doctor, caring and loving the people she cares for.