Decline in international medical graduates exacerbates shortage of general surgeons

Jul 07, 2010

A decline in the number of international medical graduates (IMGs) is threatening patient access to quality surgical care, according to a new study in the June issue of the Journal of the American College of Surgeons.

For years, a flat supply of new U.S.-educated graduates in the specialty of general surgery has created a strong need for IMGs, graduates of medical schools located outside the U.S. and Canada. The study reveals that a decline in IMGs practicing general surgery in the U.S. is creating a "crisis of urgency" as demand for general surgeons continues to grow.

Rural areas are particularly threatened by this trend. In 2005, IMGs represented 17.4 percent of all general surgeons; now they represent only 14.8 percent. Meanwhile, since 2005, the total number of rural surgeons has declined nearly 40 percent to 998, according to researchers. By 2020, the growth of the U.S. population and proportion of people older than 65 years of age will create a greater demand for healthcare resources, including surgeons. In 2020, it is estimated that the supply of general surgeons will fall short of the demand by 1,875.

"We are currently unable to fill our general surgery residencies with U.S. medical school students," said Kyla P. Terhune, MD, a general surgical resident at Vanderbilt University School of Medicine, Nashville, Tenn. "In the 2009 residency match, if every U.S. senior medical student had been matched to a first-year position in any field, only 70 percent of available positions would have been filled. These shortages can have a lasting impact on patient access to care, particularly in trauma and critical care situations."

While IMGs have long been relied upon to meet the growing need for general surgeons, the number of IMGs in practice is declining. This decline, along with inadequate numbers of trainees in domestic surgery programs, has created a critical gap. To help address future demands, 108 of the 126 existing medical schools (86 percent) are increasing class size, with a projected expansion of allopathic (conventional or Western medicine) graduates by 5,000 each year through 2020.

In this study, an assessment of the National Resident Matching Program's 2009 Main Residency Match showed 22,427 total positions in all specialties offered at a postgraduate year (PGY)-1 level. However, only 15,638 senior students enrolled in U.S. allopathic medical schools submitted rank lists (the process in which applicants bid for or "rank" their preferred residency programs) for those positions. And while the number of U.S. seniors submitting rank lists in 2009 increased by 919 from 2005, the number of senior medical students submitting for general surgery spots actually decreased by 72 applicants. On a positive note, there is recent evidence that this year more seniors are interested in general surgery; even so, this country remains dependent on a dwindling pool of IMGs.

Recently, the Physician Workforce Enhancement Act of 2009 was introduced to alleviate some of these workforce shortages by providing loans to eligible hospitals to help establish residency training programs. Preference would be given to rural and small urban areas, and programs would be limited to particular specialties, including family medicine, internal medicine, general surgery, and others. This legislation makes an attempt to increase the number of residency positions, a process that may lead to more qualified general surgeons in the future. But delays in passing the legislation and residency application trends means additional general surgery residents are likely to be IMGs.

"We cannot provide for our citizens through our own medical education system," said Dr. Terhune. "This study shows us that we must acknowledge the importance of IMGs - and the fact that we have become too reliant on them to meet the growing demand for all specialties, including ."

This cross-sectional study revealed that compared with their non-IMG counterparts, IMGs were older (52 ± 8 years versus 47 ± 8 years; p< 0.001), more likely to be male (93 percent vs. 82 percent; p< 0.001), and more likely to be further out of training (46 percent versus 28 percent ≥ 20 years out of training; p< 0.001). in terms of geographic distribution, there were 2,216 imgs in urban cores (15 percent of general surgeons in these areas); 223 imgs in large rural areas (12 percent of general surgeons in these areas); and 163 imgs in small rural areas (16 percent of general surgeons in these areas).

IMGs include both U.S. citizens and non-citizens who have trained abroad. The Educational Commission for Foreign Medical Graduates requires IMGs to complete four years of education at a medical school listed in the International Medical Education Directory and to obtain passing scores on the same licensing examinations that are given to U.S. graduates.

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