The Pivotal Role of the International Medical Graduate

The American Medical Association Physician Masterfile reveals 26 000 physicians who attended medical school outside the United States and Canada and who are not currently in residency, declaring pediatrics as their specialty. According to the Educational Commission for Foreign Medical Graduates (ECFMG), in 2015, 3 countries (India, Canada, and Pakistan) contributed the highest numbers of non–US-born international medical graduates (IMGs) receiving ECFMG certification. However, there were also a sizable number of certificate holders from Latin America, the Middle East, and Africa (Nigeria).¹ Non–US-born pediatricians inherently offer a broad cultural, linguistic, and ethnic diversity; as such, they may contribute to the goal in our pediatric specialty to improve workforce diversity and culturally effective health care.^2,3 IMGs (including US-born IMGs) comprise >26% of the entire physician workforce in the United States. Forty-one percent of practicing IMGs are in primary care disciplines as defined by the Association of American Medical Colleges.⁴ They play a vital role in the care of vulnerable populations in both rural and urban underserved areas.^2,5 

Non–US-born IMGs also constitute a disproportionate number of subspecialists on the pediatric academic workforce and are integral to caring for an increasingly medically complex pediatric patient population (eg, in national neonatal-perinatal medicine, 60% of all fellows in 2015 were IMGs).⁶ Discoveries from their research have shaped pediatric health care nationally and globally, and they continue to contribute to the education of the future pediatric workforce not only as teachers in training programs, but also as authors and editors of major pediatric textbooks.

However, as a group, they are often disconnected from organized medicine and leadership. For example, only 27% of non–US-born IMG pediatricians are American Academy of Pediatrics (AAP) fellows. This disengagement continues well after completion of training and may reflect the significant challenges that many non–US-born IMGs face. These challenges include transition to practice, acculturation, changing immigration requirements, and discrimination.^7,–9 Authors of a recent study from the AAP comparing job searches of pediatric residents noted that non–US-born pediatric IMGs had nearly 3 times the odds of reporting moderate or considerable job search difficulty compared with other graduating pediatric residents.⁵ A qualitative study based on in-depth in-person interviews of the professional experiences of 25 non–US-born IMGs revealed that they experienced (1) direct and indirect bias and discrimination, (2) limitations on professional opportunities, and (3) challenges in adapting to the culture and language of the United States and the different way medicine was practiced.¹⁰ Residency is a particularly difficult time for non–US-born IMGs. They must master clinical knowledge and skills but also adapt to new terminology, technology, and systems. They often feel isolated or viewed as inferior and feel guilty about their families left behind and the needs of the people in their birth country. And finally, they have fears related to their visa or immigration status.¹¹ These concerns all present opportunities for developing interventions to support non–US-born IMGs in this country.

Against this backdrop, the anti-immigrant rhetoric and proposed policies articulated and promulgated by the current US government have complicated immigration and return travel to the United States for many non–US-born IMGs. The AAP has gone on record to oppose recent increased restrictions on immigration as they affect non–US-born IMGs.¹² This advocacy not only speaks to the plight of non–US-born pediatric IMGs, including those from 6 “banned” Muslim-majority nations, but for the health care of children in the United States. In view of the present anti-immigrant climate in the United States, it seems more important than ever to speak out about supporting the needs of non–US-born IMGs.

We encourage the pediatric community to strongly support the education and professional development of non–US-born IMGs in the following ways:

• Design and implement educational interventions during residency and fellowship training to address the following known transitional problems of non–US-born IMGs: understanding English language at a high level of proficiency, including idiomatic usage; communication skills and expectations regarding patients; patient-centered care; US system of teaching and learning; cultural issues specific to the United States; basic information about the US health care system; and information regarding visa and immigration.^11,13,14 Preferentially, these programs could be for all residents and fellows, not just non–US-born IMGs. Active involvement of non–US-born IMGs in discussions and implementation of international child health to take advantage of their experiences and knowledge is also important;

• Implement specific and targeted mentorship for non–US-born IMGs across the pediatric professional continuum, designed to address individual experiences with bias and discrimination, provide support regarding visas and immigration, and guide career transitions and advancement. Peer mentoring programs could be considered as part of this mentoring “package.”¹¹ The Section on International Medical Graduates at the AAP is currently in discussion with the ECFMG on developing such a program;

• Implementation of educational and intervention programs used to address direct and indirect bias and discrimination of non–US-born IMGs during residency, fellowship, and professional practice. These could be offered as part of pediatric training programs, faculty development, and national meetings providing continued medical education. Institutional review of policies should be performed to make sure existing policies do not neglect these issues or perpetuate bias and discrimination;

• Outreach by pediatric professional organizations to non–US-born IMGs to improve their engagement and leadership in organized pediatric medicine;

• Continued advocacy regarding immigrant and refugee travel bans and other barriers affecting non–US-born IMGs. Any acute reduction in numbers of practicing non–US-born IMGs may disproportionately affect children and families in underserved communities, potentially increasing disparities in health care delivery; and

• Support of research to evaluate interventions described above to determine the most effective interventions related to specific outcomes.¹⁴ 

This is a call to action. There are important roles for professional organizations such as the Accreditation Council for Graduate Medical Education, the AAP, the Association of Pediatric Program Directors, and the ECFMG, among others, in all these efforts.

AAP

American Academy of Pediatrics

ECFMG

Educational Commission for Foreign Medical Graduates

IMG

international medical graduate