1. Comparison of Surgical Residency Applicants from U.S. Medical Schools with U.S.-Born and Foreign- Born International Medical School Graduates Paul J. Schenarts, MD, Katie M. Love, MD, Steven C. Agle, MD, MPH, Carl E. Haisch, MD Division of Surgical Education Department of Surgery East Carolina University

2. Introduction Impending physician shortage Evolving crisis in access to emergency surgical care and aging population One solution = increase number of international medical graduates (IMG)

3. Introduction International medical graduates’ contributions: More frequently provide care to underserved and rural populations 1 Contribute to surgical research –21% of principal investigators of NIH research projects 2 Account for 19% of U.S. medical school faculty 2 Enter academic surgery at rates comparable to US graduates 3 1.Howard et al, 2006 2. Alexander et al, 2007 3. Arannha, 1998

4. Problem The perception of the quality of IMGs’ educational preparation and performance is variable Negatives: –Discrimination by program directors 1 –Diminished reputation –Cultural and communication issues –Higher failure rates on the Board Exam 2 –1,935 different medical schools Positives: –Several programs actively seek IMGs 1. Moore & Rhondenbaugh, 2002 2. Norcini, et al, 2006

5. Purpose Compare applicant characteristics of US medical school graduates with US-born and foreign-born international medical graduates.

6. Methods IRB and GME approval Retrospective analysis All 2007 ERAS applicants to our general surgery residency Definition of US graduates –Allopathic and osteopathic medical schools –Foreign-born US graduates Graduates from outside the US, were considered IMGs Assignment to US-born or foreign-born IMG groups was based on self reported country of birth

7. Methods Data points: Demographic data - Age- Visa status - Gender- Citizenship - Couples match- Current residence USMLE performance Number of scholarly works (presentations, publications) Attainment of advanced degrees Employment history since medical school graduation

8. Methods Analysis: T-test and Chi square

9. Results: Demographics U.S. Graduates U.S.-Born IMG Foreign-Born IMG Applicants: 166 85 321 Age (Years): 28.9  3.2 29.9  3.5 * 33.0  6.6 ‡ Male Gender: 70% 80% 86% ‡ U.S. Citizenship: 97% 100% 15% † Living in the U.S.: 100% 100% 79% ‡ Couples Match: 3.6% 1.2% 1.9% Data presented as mean  standard deviation or percent. Statistical comparisons are with U.S. graduates only. * p<0.05, † p<0.01, ‡ p< 0.0001

10. Results: Visa types for Foreign-Born IMGs Permanent Resident 28% B-117% U.S. Citizen15% B-210% J-1 9% F-1 7% Other 5% H-1B 4% H-4 2% EAD 1% Refugee/Asylum 1% TN NAFTA 1%

11. Results: Medical School Location U.S. Graduates U.S.-Born IMG Foreign-Born IMG United States (100%)Caribbean (70%) South Asia (29%) South Asia (9%) Middle East (16%) Central America (6%) Caribbean (9%) Middle East (5%) China (8%) Eastern Europe (3%) Central America (7%) South America (3%) Eastern Europe (7%) South Pacific (2%) South America (5%) Africa (1%) Africa (4%) United Kingdom (1%) Central Asia (3%) Russia (3%) United Kingdom (2%) Western Europe (2%) Southeast Asia (2%) Mediterranean (1%) Northern Europe (1%) South Pacific (1%)

12. Results: USMLE Performance U.S. Graduate U.S.-Born IMG Foreign-Born IMG USMLE step 1: 206  20 200  26 202  28 Multiple attempts: 9% 20% † 24% ‡ USMLE step 2: 213  23 201  29 † 203  31 † Multiple attempts: 4% 22% ‡ 19% ‡ Data presented as mean  standard deviation or percent. Statistical comparisons are with U.S. graduates only. * p<0.05, † p<0.01, ‡ p< 0.0001

13. Results: Pre-application Experience U.S. Graduates U.S.-Born IMG Foreign-Born IMG Yrs since graduation:0.3  0.7 1.5  1.9 ‡ 7.7  6.8 ‡ Advanced degree: 11% 13% 19% † (Masters / PhD)(84% / 6%) (91% / 9%) (77% / 23%) Scholarly works:1.7  3.0 0.9  2.0 † 3.9  8.4 † Jobs since graduation:0.3  0.5 2.2  2.2 ‡ 5.1  3.9 ‡ Data presented as mean  standard deviation or percent. Statistical comparisons are with U.S. graduates only. * p<0.05, † p<0.01, ‡ p< 0.0001

14. Results: Most Common Jobs Since Graduation U.S. Graduates U.S.-Born IMG Foreign-Born IMG 18% Prelim Surgery15% Research 45% International Surg 2% Research13% Prelim Surgery44% Research 2% Other medicine13% Observership40% Other medicine 38% Observership 15% Prelim Surgery 13% Other medicine 12% Tech / assistant

15. Discussion: US-Born IMGs compared to US graduates Positive attributes: Slightly older and hold more advanced degrees Research experience Clinical experience in prelim surgery or medicine Similar USMLE Step 1 scores Negative attributes: Required multiple attempts to pass Step 1 and 2 Significantly lower Step 2 scores Fewer scholarly works

16. Discussion: Foreign-Born IMGs compared to US graduates Positive Attributes: Hold more advanced degrees, particularly more PhDs Similar USMLE Step 1 scores More scholarly activity Greater research experience Significantly more clinical experience in international surgery or other medical fields

17. Discussion: Foreign-Born IMGs compared to US graduates Negative attributes: Older Significant time between graduation and application Lower USMLE Step 2 scores Required multiple attempts to pass Step 1 and 2

18. Discussion: While most IMGs are living in the U.S., their medical schools are often located in areas of the greatest health care need Draining these areas of the best and brightest to meet U.S. needs may have ethical, social and political repercussions

19. Discussion: Limitations Retrospective Self-reported data Moderate size, single institution Rural location Did not determine which factors predict success

20. Conclusions: IMGs offer many attributes program directors and selection committees favor Older applicants, who graduated several years ago, and have trouble passing standardized tests may have a difficult time IMGs may help solve the shortage of physicians, however, residency programs will need to address communication, cultural differences, and test taking skills