1. DOCTORS ON THE MOVE   TRENDS, IDENTITIES, PROBLEMS DOCTORS ON THE MOVE   TRENDS, IDENTITIES, PROBLEMS Buz Cooper AcademyHealth San Diego June 5, 2004

2.     IMG TRENDS Certification by Educational Commission on Foreign Medical Graduates (ECFMG) and Participation in Residency Programs

3. RESIDENTS w/o PRIOR RESIDENCY 1950-2002 AMA, AAMC,AOA, AACOM

4. RESIDENTS w/o PRIOR RESIDENCY 1950-2002 AMA, AAMC,AOA, AACOM

5. EVENTS INFLUENCING FIRST TIME IMG RESIDENTS 1950-2002 Post WW II demand 1998CSA Period of medical school expansion 1976 Health Professions Act restrictions 1991 Increase in H1b Visas ************ Proposed exam change 1985 COBRA restrictions ************************* Medicare IME

6. FIRST TIME IMG PGY-1 RESIDENTS and ECFMG CERTIFICATIONS 1991 Expanded access to temporary to temporary(H1-B) visas visas 1992 1992Proposed exam change 1998CSAintroduced 1985COBRArestrictions 1976 Health Professions Education Act 1995 1995Computerizedexam ECFMG and JAMA

7.     TRENDS in IMGs in the US Who are they?

8. ECFMG CERTIFICATES 1960-2002 ECFMG

9. Average Number of Entering IMG Residents 1995-2002 and ECFMG Certificates 1994-2001 Entering residents = 246 (viapp) From ECFMG.

10. IMG PGY-1 RESIDENTS 1995-2002 ECFMG

11.     Interest in the US Among Foreign Medical Students

12. Survey of Medical Students at Bangalore-Ramiah Medical College and Bangalore Medical College INDIA Raghu Rao and Richard Cooper 2004 Preliminary data analysis

13. Survey of Indian Medical Students Rao and Cooper, 2004 %

14. Survey of Indian Medical Students Rao and Cooper, 2004 %

15. Survey of Indian Medical Students Rao, 1998 Academic Psychiatry Rao and Cooper, 2004 %

16. International Market for Medical Doctors National Primary Care Research and Development Center Manchester Center for Healthcare Management Manchester, England 2003 A wide range of “demander countries” is looking to source a substantial proportion of their medical labour supply from outside their own health systems. A wide range of “demander countries” is looking to source a substantial proportion of their medical labour supply from outside their own health systems. The hegemonic position of the USA was perceived as unassailable. The hegemonic position of the USA was perceived as unassailable.

17.     Staying After Residency

18. J1 Visa Waiver of 2-year return requirement ( 4,798 waivers ) Primary care or general psych in underserved area- three years State Conrad-30 Program --- up to 30 waivers per state Delta Regional Commission --- 8 states, 240 counties Appalachian Regional Authority ~ 250 counties Veterans Administration, HHS --- few Pending Bills: J1 waivers for specialists in hospitals serving underserved Redistribution of unused waivers ---1,500 available, 1200 used H1b Visas Program expired Sept. 30, 2003: 195K  65K visas Exemptions: Conrad 30 waivers of J1 visa requirements while in waiver Residents in a “university Sponsorship by nonprofit, university or government Opportunities to Remain without an H1b visa National interest waiver Tourist visa Extension of J1 to take exam Small business (Canadians) under NAFTA Bill pending to exempt former J1 visa holders from H1b cap AFTER RESIDENCY: J1 and H1b Visas

19. The number of IMGs has varied with changes in immigration policy, reimbursement policy and exam-certification, but the trend has been upward. The number of IMGs has varied with changes in immigration policy, reimbursement policy and exam-certification, but the trend has been upward. Half of all IMGs are from South Asia, North Africa and the Middle East, where visa problems are the greatest. Half of all IMGs are from South Asia, North Africa and the Middle East, where visa problems are the greatest. Foreign medical students are encountering Foreign medical students are encountering increasing difficulty in accessing the US system, greater demand from the UK and Canada, more obstacles to remaining in the US after training, and better opportunities at home.    CONCLUSIONS

20. Thank you.

22. Entering IMG Residents 1995-2002, % of GRADUATES in HOME COUNTRY Adapted from ECFMG and Eckhert, 2002

23. Survey of Indian Medical Students Rao and Cooper, 2004 %

24. Survey of Indian Medical Students Rao and Cooper, 2004 %

25. Survey of Indian Medical Students Rao and Cooper, 2004 %

26. Survey of Indian Medical Students Rao and Cooper, 2004 %

27. Survey of Indian Medical Students Rao and Cooper, 2004 %

28. Survey of Indian Medical Students Rao and Cooper, 2004 %

29. Concerns US-IMGs vs. Foreign IMGs Quality of educational programs Rate of disciplinary actions Hurdles USMLE Steps 1, 2, 3 Clinical Skills Assessment (CSA) (cost, time) Visas to take CSA exam Visas to enter for residency Decreased availability of H1b visas (195K in 2003  65K in 2004) Competition England Canada Attractiveness of native countries IMG CHALLENGES

30. ECFMG Certificates 1993-2002

31. ECFMG CERTIFICATES 1995-2002

32. RESIDENTS 1995-2002

33. PERCENT of IMGs from before 1997 who are CURRENTLY ACTIVE in the AMA MASTERFILE

34. IMGs (all years) Citizenship or Visa Status Corrected for unknown

35. IMGs (all years) Visa Status Corrected for unknown

36. First Time PGY-1 Residents and ECFMG Certificates Potential IMGs  IMGs  2,000  F-IMGs   F-IMGs   US IMGs   US IMGs  DOs DOs