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Pdf Examination Performances of U.S U.S. Health Care Workforce By John J. Norcini, John R. Boulet, W. Dale Dauphinee, Amy Opalek, Ian D. Krantz, and Suzanne T. Anderson doi: 10.1377/hlthaff.2009.0222 HEALTH AFFAIRS 29, NO. 8 (2010): 1461–1468 ©2010 Project HOPE— Evaluating The Quality Of Care The People-to-People Health Foundation, Inc. Provided By Graduates Of International Medical Schools John J. Norcini (jnorcini@ ABSTRACT One-quarter of practicing physicians in the United States are FAIMER.org) is president and graduates of international medical schools. The quality of care provided chief executive officer of the Foundation for Advancement by doctors educated abroad has been the subject of ongoing concern. Our of International Medical Education and Research analysis of 244,153 hospitalizations in Pennsylvania found that patients (FAIMER), in Philadelphia, of doctors who graduated from international medical schools and were Pennsylvania. not U.S. citizens at the time they entered medical school had significantly John R. Boulet is associate lower mortality rates than patients cared for by doctors who graduated vice president for research and data resources at from U.S. medical schools or who were U.S. citizens and received their FAIMER. degrees abroad. The patient population consisted of those with congestive heart failure or acute myocardial infarction. We found no W. Dale Dauphinee is a senior scholar at FAIMER. significant mortality difference when comparing all international medical graduates with all U.S. medical school graduates. Amy Opalek is a data resource specialist at FAIMER. Ian D. Krantz is an associate professor of pediatrics at the Children’sHospitalof raduates of international medical We hope that the results will serve as a spring- Philadelphia and the Division schools make up approximately board for changes in medical education practices of Human Genetics and Molecular Biology at the one-quarter of U.S. practicing and opportunities. University of Pennsylvania, in 1,2 physicians. Their numbers have As a first step to entering the United States, Philadelphia. varied over time with changes in graduates of international schools must be cer- Gimmigration policy, health care provider needs tified by the Educational Commission for For- Suzanne T. Anderson is senior in the United States, and a host of other factors. eign Medical Graduates (ECFMG). This vice president, chief financial officer, and chief information However, proposed responses to the existing certification process includes primary-source officer at the Virginia Mason and projected U.S. physician shortageraise im- verification of graduates’ educational creden- Medical Center, in Seattle, portant policy considerations regarding tials, such as medical school diplomas and tran- Washington. international medical graduates.3 scripts. It also includes successful performance on the first two steps of the U.S. Medical Licens- ing Examination (USMLE). To obtain a license, Background graduates of international schools must acquire U.S. medical schools have reacted to the physi- accredited residency training in the United cian shortage by increasing their class sizes; new States and pass the third step of the examination. medical schools have also been created. How- At the completion of their training, graduates ever, the number of residency positions has can seek specialty board certification, which re- not increased proportionately.4,5 The increased quires additional testing. class size offers U.S. citizens who might other- Despite this rigorous process, there has been wise have gone abroad for medical school the ongoing concern about the competence of grad- opportunity to stay home and study. But a re- uates of international schools. A 1991 summary stricted number of residency positions means of the literature concluded that on certain mea- fewer opportunities for both U.S. and sures of quality, these graduates did not do as international graduates. This study provides well as graduates of U.S. medical schools.6 For data on the outcomes of care by both groups. instance, international graduates performed August 2010 29:8 Health Affairs 1461 U.S. Health Care Workforce worse than U.S. medical school graduates on tals, skilled nursing facilities, and state licensing examinations. International graduates psychiatric hospitals that perform inpatient also scored lower on program directors’ ratings services—to submit a record for each discharge. and specialty board certification rates in internal The facilities gave uniform billing standards data medicine—the most popular specialty for directly to the council. They were also required to international graduates.7–11 However, by the report patient demographics; coexisting health mid-1990s, international medical graduates conditions; and key clinical findings, such as were outperforming U.S. graduates on in- patient history, laboratory values, vital signs, training examinations in internal medicine.12 and clinical signs and symptoms, from the begin- Of special interest are U.S. citizens who go ning of the inpatient stay. abroad for medical school. They constitute about These data were submitted to MediQual, an one-fifth of the international graduates certified independent clinical information management by the Educational Commission for Foreign business offering health care quality measure- Medical Graduates, and the vast majority of them ment support services, where a proprietary risk seek graduate training in the United States.2 calculation model was applied to derive the Atlas International graduates who are U.S. citizens, Admission Severity index.21 This index is an in- especially those who attended medical schools dication of how sick the patient was on admis- in the Caribbean, do not perform as well as U.S. sion; it is expressed on a scale reflecting the graduates or international graduates who are not probability of death. The index and probability U.S. citizens on the USMLE or on specialty board of death range from “no clinical instability” with exams.8,13–15 less than a 0.1 percent probability of death to Much of the research on the competence of “maximal instability” with greater than a international graduates has focused largely on 49.9 percent probability of death. This severity educational measures of quality. A more funda- index was sent to the Pennsylvania cost contain- mental question is this: Are there differences in ment council, where it was combined with the clinical outcomes for patients cared for by these inpatient records. physicians? In a 1991 review, Stephen Mick and Using a common identifier, we matched the Maureen Comfort found that the research was council’s data with both the 2008 American insufficient to answer that fundamental ques- Medical Association (AMA) Physician Masterfile tion. Since then, however, the ability to use in- and the Educational Commission for Foreign formation on patient outcomes to assess the Medical Graduates database. The AMA Master- effectiveness of groups of physicians has im- file contains information on all physicians who proved.16–19 reside in the United States and have met the This study examines inpatient death rates credentialing requirements necessary for recog- and lengths-of-stay for patients with congestive nition. The ECFMG database contains informa- heart failure or acute myocardial infarction—or tion on all international graduates who have heart attack—cared for by non-U.S.-citizen attempted to establish their readiness for resi- international graduates, U.S.-citizen inter- dency training in the United States. national graduates, and U.S. medical school We selected hospitalizations with a principal graduates. These two patient conditions were diagnosis of congestive heart failure or acute chosen because they are common, and the pre- myocardial infarction because they are common ponderance of care for them is provided by in- conditions and are often used as markers of qual- ternists, family physicians, and cardiologists. ity of care.22 Congestive heart failure hospitaliza- These specialties account for 44 percent of all tions were excluded if the patient was younger international medical graduates in active prac- than eighteen, the discharge disposition was tice in the United States; focusing on them al- missing, or the patient was transferred to an- lowed for the level of specialization—primary other short-term hospital. Acute heart attack care versus cardiology—to be controlled for in hospitalizations were excluded if the patient the analysis.20 was younger than eighteen, the disposition when the patient was discharged or the admis- sion source was missing, or the patient was Study Data And Methods transferred to or from another short-term Data Sources And Participants We conducted hospital. a retrospective study using inpatient records We further limited our analyses to hospitaliza- from Pennsylvania for the period from January 1, tions where the attending physician graduated 2003, to December 31, 2006. The data were ob- from medical school after 1958, the year the Ed- tained from the Pennsylvania Health Care Cost ucational Commission for Foreign Medical Grad- Containment Council, which required all facili- uates was established. The attending physician ties in the state—except Veterans Affairs hospi- pool was also restricted to those who specialized 1462 Health Affairs August 2010 29:8 dent of time in practice, institutional experience, Are there differences and patient characteristics. Analyses Descriptive statistics were calcu- in clinical outcomes lated at the level of the
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