Work Experiences and Satisfaction of International Medical School Graduates

We analyzed cross-sectional data collected in 2015 from PLACES, a national, longitudinal study in which the work and life experiences of pediatricians across their careers are tracked.¹⁷ Participants in PLACES are surveyed twice yearly. In this study, we focus on data collected in 1 of these surveys.

Participants in PLACES were identified by using an AAP database that includes all pediatricians who completed US residency programs (both AAP members and nonmembers). The following 2 cohorts of pediatricians were recruited in 2012 on the basis of their residency graduation date: 2009–2011 and 2002–2004. Thirty-nine percent of pediatricians who were randomly selected to participate in PLACES signed up for the study and completed the first study survey. Details regarding PLACES methodology, including the target population, sample size analysis, and nonresponse and poststratification weights, are previously described.¹⁷ Initial study weights were calculated because nonresponse bias tests revealed that participants were significantly more likely to be women, AAP members, and graduates of US medical schools than pediatricians in the respective target cohorts. For the current study, these initial study weights were adjusted on the bases of sex, AAP membership status, and the medical school location of participants who completed the 2015 survey, and they were applied to all analyses in this article.

We analyzed data from 1 of the PLACES surveys conducted in 2015 (April–September) via e-mail and surface mail depending on participant preference. Participants received a $20 Amazon.com gift card for completing the annual survey. The AAP Institutional Review Board approved the study.

The domains and questions for the PLACES surveys were developed through (1) content prioritization by a project advisory committee; (2) literature review to identify related, existing questions; and (3) cognitive interviews and pilot tests to assess how questions were interpreted by participants. When available, survey questions were adapted from other physician studies, including the Physician Worklife Study,^18,19 Medicine in Australia: Balancing Employment and Life,²⁰ and the AAP Annual Survey of Graduating Residents,²¹ among others.^22,–24 In the current article, we focused on the following domains: work characteristics, financial experiences, and job satisfaction.

The analytic sample included pediatricians who participated in the 2015 survey, answered questions about their backgrounds (eg, medical school location and childhood location) on a previous survey, and were not in fellowship training in 2015. Participants were categorized into the following 3 groups by their reported childhood and medical school locations⁵: (1) international childhood and medical school graduate (international-IMG), (2) United States childhood and international medical school graduate (US-IMG), and (3) United States or international childhood and United States medical school graduate (USMG). Unlike previous researchers,⁵ we combined pediatricians who grew up outside of the United States and graduated from a US medical school with the other US medical school graduates because the number of respondents was small (n = 39) and their training experiences were similar to those of USMGs.

χ² tests were used to examine whether (1) demographic characteristics, (2) work characteristics, (3) financial experiences, and (4) job satisfaction factors varied by the 3 childhood–medical school location groups. Multivariable logistic regression was used to identify associations (if found in the bivariate results) for work characteristics (8 models), financial experiences (5 models), and job satisfaction (5 models) among the 3 childhood–medical school groups while controlling for pediatrician demographic characteristics, including cohort (2009–2011 residency graduates or 2002–2004 residency graduates), sex (male or female), race and ethnicity (white and non-Hispanic, Asian and non-Hispanic, or other [including Hispanic, African American, or black]), marital status (yes or no), whether a respondent has children (yes or no), educational debt in 2015 (<$100 000 or ≥$100 000, including a spouse’s or partner’s debt, if applicable), and region of the country (Midwest, Northeast, South, or West). Educational debt was also examined as an outcome. Annual income (≥$200 000 or <$200 000) was also included in 3 of the financial characteristic models (retiring savings are on track, owns primary residence, and has no financial worries) and all of the satisfaction models.

All data presented were weighted as described above. All analyses were conducted with PASW Statistics 22 (SPSS Inc, Chicago, IL), using P ≤ .05.

A total of 88% of the participants in PLACES (1587 of 1804) completed the 2015 survey. Of the 1467 participants in the analytic sample, 13% (n = 186) grew up outside of the United States and graduated from an international medical school, 6% (n = 91) grew up in the United States and graduated from an international medical school, and 81% (n = 1190) graduated from a US medical school.

The 3 childhood–medical school groups varied by sex, marital status, race and ethnicity, language proficiency, and region of the country (Table 1). Pediatricians who graduated from international medical schools were less likely than the US graduates to report being white and non-Hispanic, and they were more likely to report proficiency communicating with patients in languages other than English. Approximately one-fourth of the international-IMG, 32.2% of the US-IMG, and 71.3% of the USMG groups self-identified as white and non-Hispanic, and 72.9% of the international-IMG, 64.4% of the US-IMG, and 31.3% of the USMG groups reported proficiency in other languages.

Physicians in the 3 childhood–medical school groups also varied by professional characteristics, including current position, part-time work, work area and setting, having ≥50% of patients with public insurance, agreement that physician colleagues value their work and are important sources of personal support, and likelihood of leaving their jobs in the next 2 years (Table 2). For example, 43.5% of those in the international-IMG group, 40.3% of those in the USMG group, and 29.7% of those in the US-IMG group were working as subspecialists in 2015. In a multivariable analysis (Table 3), physicians in the international-IMG group were less likely than those in the USMG group to work part-time hours (adjusted odds ratio [aOR] 0.56; 95% confidence interval [CI] 0.33–0.96), agree that their physician colleagues value their work (aOR 0.35; 95% CI 0.21–0.56), and agree that their physician colleagues are an important source of personal support (aOR 0.58; 95% CI 0.41–0.83). They were more likely than physicians in the USMG group to work in an urban, inner-city area, work at a practice, have ≥50% of their patients covered by public insurance, and plan to leave their job in the next 2 years. Physicians in the US-IMG group were less likely than those in the USMG group to work as subspecialists (aOR 0.49; 95% CI 0.29–0.83), and they were more likely to work in a practice setting (aOR 1.72; 95% CI 1.08–2.74) and care for more patients with public insurance (aOR 2.12; 95% CI 1.31–3.42).

Physicians in the 3 childhood–medical school groups had different financial experiences (Table 2). For example, 16.7% of those in the international-IMG group, 73.6% of those in the US-IMG group, and 82.7% of those in the USMG group had educational debt at residency graduation, and 9.7% of those in the international-IMG group, 51.1% of those in the US-IMG group, and 35.2% of those in the USMG group reported at least $100 000 of debt in 2015 (including spouse or partner debt, if applicable). In a multivariable analysis (Table 4), the physicians in the international-IMG group were less likely than those in the USMG group to have educational debt at residency (aOR 0.04; 95% CI 0.03–0.06), have educational debt in 2015 (aOR 0.13; 95% CI 0.08–0.23), and own their primary home (aOR 0.58; 95% CI 0.36–0.93). Physicians in the US-IMG group were more likely than those in the USMG group to have educational debt in 2015 (aOR 2.55; 95% CI 1.53–4.25).

The majority of participants in all 3 groups (70.7%–88.4%) reported overall job (agree that work is personally rewarding) and career (agree that they are satisfied with their careers as physicians) satisfaction levels (Table 2). Fewer reported satisfaction with their salaries (26.6%–38.2%), the nonmonetary aspects of their jobs (39.1%–48.9%), and their job benefits (30.4%–50.6%). The 3 childhood–medical school groups varied on all 5 measures of satisfaction, with the international-IMG group being the least satisfied on all the measures (Table 2). In a multivariable analysis (Table 5), physicians in the international-IMG group were less likely than those in the USMG group to report satisfaction with their salaries (aOR 0.61; 95% CI 0.41–0.90), the nonmonetary aspects of their jobs (aOR 0.60; 95% CI 0.42–0.85), and their job benefits (aOR 0.33; 0.22–0.47) and reported lower overall work satisfaction (agree that work is personally rewarding; aOR 0.27; 95% CI 0.18–0.41) and career satisfaction (aOR 0.41; 95% CI 0.27–0.62). Physicians in the US-IMG group were less likely than those in the USMG group to be satisfied with their job benefits (aOR 0.50; 95% CI 0.30–0.82).

Using national data from the AAP PLACES, we found differences in demographic and work characteristics, financial experiences, and satisfaction levels among 3 groups of early-career and midcareer pediatricians, whom we classified by their childhood locations and medical school locations (international-IMG, US-IMG, and USMG). Key findings of the study include that international-IMGs feel less valued and supported by their physician colleagues at work, and although strong majorities of all groups report job and career satisfaction, international-IMGs are the least satisfied with these domains as well as with their salaries and benefits. The study may have implications for IMGs and pediatric workforce policies. Residency program directors who routinely train IMGs may be interested in these findings because IMGs constitute one-fourth of the pediatric trainees.

Demographically, both international-IMGs and US-IMGs in our study were more varied compared with USMGs, especially in terms of race, ethnicity, and being multilingual. Researchers in other studies have also found that IMGs in other specialties have similar demographic characteristics.^5,6,13,25,26 Almost one-half of Hispanic pediatricians in our sample graduated from an international medical school. This is an important finding given the increasing proportion of Hispanic children in the US population,²⁷ the shortage of Hispanic pediatricians,²⁸ and commitments to workforce diversity by organizations, including the AAP.²⁹ Patients of IMGs are more likely to be minorities and immigrants and live in neighborhoods where English is poorly spoken or not spoken at all.⁶ From a health care delivery perspective, it is important to understand patient-provider concordance and provide linguistically and culturally appropriate care to improve health care access for minorities.³⁰ 

Compared with physicians in the USMG group, those in the international-IMG group were more likely to work full-time; work in a practice setting in an urban, inner-city area; see patients on public insurance; and have plans to move to a new job. The finding that international-IMGs tend to work full-time may be reflective of minimum work-hour restrictions associated with their visas.³¹ Researchers in multiple studies have reported that IMGs tend to work in underserved areas in which patients with public insurance are seen.^{10,13,25,32,–34} The US federal government offers the J-1 visa waiver program, through which IMGs can commit to work in designated Health Professional Shortage Areas for 2 years in lieu of returning to their home countries.³⁵ The program includes benefits for IMGs as well as for the programs designed to care for underserved populations. It was also previously reported that IMGs change their jobs more often and leave underserved areas after completing work obligations.^13,35 Physician turnover has big financial impacts (>5% of the total annual operating budget) due to hiring, training, and loss of productivity on health care entities, some of which can least afford it.¹⁶ Employers’ understanding and support of the immigration process may play a positive role in IMG job satisfaction.

In our study, we collected information on financial characteristics, and although some of the similarities and differences among the groups were expected, others were not, and they may warrant further study. As anticipated, international-IMGs reported much lower educational debt than those graduating from US medical schools. Tax funding of medical education in their home countries has been shown to reduce levels of debt.³⁶ Although we found that the groups reported similar salaries, retirement savings, and financial concerns, the international-IMGs were less likely to report home ownership and satisfaction with their salaries, benefits, and jobs. Physicians in this group may not want to establish more permanent residences because of the temporal nature of visa status and/or the location of their jobs (eg, inner city). The lower levels of satisfaction with salary and benefits among this group was not expected. The Society for Human Resource Management reports that the top contributors to employee job satisfaction are respectful treatment, compensation, benefits, and job security.³⁷ Researchers in future studies might explore if feeling less supported and/or valued by colleagues or working under visa restrictions, possibly with employers offering less-generous job benefits, helps to explain the lower satisfaction.

Researchers in several studies have reported lower satisfaction levels among IMG physicians.^{8,–10,13,32} Compared with other studies which looked at career satisfaction as a singular outcome,^11,–15 our study attempted to look at additional facets of physician satisfaction, including salary, nonmonetary aspects, work, and career, confirms the findings in other publications that IMGs report lower job satisfaction.^11,–15 Measures of physician satisfaction across different domains might be used in recruitment and retention efforts if these areas can be addressed.

International-IMGs in our study were also less likely to feel valued or supported at work by their physician colleagues. A big part of job satisfaction is collegial recognition and support, a lack of which has also been reported in other studies.^13,32 The reasons for this perception among IMGs might be cultural, procedural, and/or system related. Some of these factors have been observed in other groups, including minority physicians, female physicians, and international nursing graduates.¹³ 

A recent study of a cohort of IMG found that faculty and peers perceive IMG performance to be comparable to that of USMGs, with IMGs excelling in clinical knowledge and skills and underperforming in communication, public health knowledge, and efficiency.³⁸ Challenges facing IMGs are both cultural and noncultural, including patient-centered care, shared decision-making, lower hierarchy and loss of status, subtleties of language, navigating the health care system, science-oriented medical education, and immigration requirements.³¹ Support services in the form of acculturation strategies that include training in language, culture, and traditions can be helpful.^35,39 The Educational Commission for Foreign Medical Graduates IMG Advisor Network is a platform connecting practicing IMG physicians and trainees.⁴⁰ Institutionally, structured mentoring, workplace policies preventing bias, language proficiency, and promoting cultural sensitivity toward IMGs can be implemented, but they require further research.^13,41,42 

IMGs who train on a J-1 visa frequently seek work in underserved areas to qualify for the waiver program. Initiatives to support IMGs by those in state waiver offices and employers could be used to improve integration into rural and underserved communities.⁴¹ Mentoring programs with past recipients of J-1 waivers may be helpful. Changes to the structure of J-1 programs should be made while keeping in mind the health care needs of underserved communities. IMG physician organizations can aid physician acculturation via training workshops and modules with role-play, case studies, and patient scenarios.⁴³ Those in medical organizations with a significant IMG presence might consider forming an IMG group,³² such as the AAP Section on International Medical Graduates.⁴⁴ 

US-IMGs, as observed in previous literature, constitute an important part of the workforce, especially in primary care.⁴⁵ Our research reveals some important similarities and differences between the international-IMG and US-IMG groups in our sample. They both differ from USMGs in terms of race, ethnicity, and language, and physicians in the international-IMG and US-IMG groups care for more patients with public insurance than those in the USMG group. They are different in that physicians in the international-IMG group tend to subspecialize, feel less supported and valued by colleagues at work, and experience less satisfaction than US-IMGs. Physicians in the US-IMG group have more educational debt. Approximately one-half still had educational debt >$100 000 in 2015, indicating that policies that better support these pediatricians before and after training may be helpful.

These results should be interpreted while considering our study’s strengths and limitations. First, these data were self-reported, including medical school and childhood locations, and are limited to early-career and midcareer pediatricians. Second, although the participation rate among PLACES pediatricians who completed the 2015 survey was high, the initial project enrollment rate was lower (41%).¹⁷ However, efforts were made to account for nonresponse bias by using a data-weighting procedure. Third, we do not have information on US citizenship; we used childhood location to define our groups instead of citizenship. Fourth, physician retention and satisfaction are complex issues, and there may be other factors that were not measured in our study that contribute to these findings. The rapid changes in health care policies, including reimbursement and other mandates for providers, will undoubtedly change factors associated with the domains we measured. The study’s strengths include its large, national sample and the timing of the data collection from IMGs, which was several years after their residency graduation.

In our national study, nearly 1 in 5 early- to midcareer participants are IMGs. International-IMGs and US-IMGs are more racially diverse and multilingual. International-IMGs are more likely to work full-time and care for children with public insurance in urban, inner-city areas. Despite low levels of educational debt, international-IMGs report decreased home ownership. They face unique challenges, such as feeling less supported and valued at work, and are less satisfied with their salaries and benefits. Overall, international-IMGs report lower satisfaction levels with their careers as physicians and are more likely to leave their jobs in the next 2 years. The results of this study might be used to inform policy discussions regarding immigration and visa requirements, J-1 visa waiver policies, acculturation strategies, and workforce diversity.

 
• AAP

  American Academy of Pediatrics

 
• aOR

  adjusted odds ratio

 
• CI

  confidence interval

 
• IMG

  international medical school graduate

 
• international-IMG

  international childhood and medical school graduate

 
• PLACES

  Pediatrician Life and Career Experience Study

 
• USMG

  United States or international childhood and United States medical school graduate

 
• US-IMG

  United States childhood and international medical school graduate

We thank the pediatricians participating in PLACES, who all gave generously of their time to make this project possible. Members of the PLACES Project Advisory Committee include the following: Bobbi J. Byrne, MD, FAAP, chairperson; Gary L. Freed, MD, MPH, FAAP; Shesha Kalyan Katakam, MD, MPH, FAAP; Laurel K. Leslie, MD, MPH, FAAP; Ashley A. Miller, MD, FAAP; and Amy J. Starmer, MD, MPH, FAAP.