Findings Brief: November, 1997
Leonard D. Baer, MS
Thomas C. Ricketts, Ph.D., MPH
Thomas R. Konrad, Ph.D.
NC Rural Health Research and Policy Analysis Program
Cecil G. Sheps Center for Health Services Research, UNC-Chapel
Hill
The benefit of international medical graduates (IMGs) in compensating
for local physician shortages may be offset by the financial burden
of a national physician oversupply. Since 1988, the rate of growth
in the number of international medical graduates in residency
training and practice in the United States has exceeded the growth
of domestic medical graduates. The number of IMG residents has
increased more than twofold between the 1988-89 academic year
and the 1995-96 academic year. Such a dramatic increase was made
financially possible, at least in part, because the Medicare program
has been financing a substantial portion of US graduate medical
education. As the number of IMGs in residency programs and the
US physician workforce has increased, many policymakers have become
concerned that there are too many international medical graduates
competing for residency positions, employment opportunities, and
public funds with US medical graduates. Yet any reduction in the
number of international medical graduates may affect access to
health care in rural areas, particularly if IMGs are practicing
in rural, underserved areas.
To better understand whether IMGs are likely to practice in rural,
underserved areas, this study calculated the percentage of primary
care IMGs in the US primary care physician workforce in rural
areas. The data were stratified by Health Professional Shortage
Area (HPSA) designation as a measurement of underservice, resulting
in separate IMG percentages for rural, whole county HPSAs, partial
county HPSAs, and non-HPSAs. The study uses the 1996 American
Medical Association Physician Masterfile and the U.S. Bureau of
Health Professions 1997 Area Resource File.
International Medical Graduates as Percentage of Physicians in
Nonmetropolitan Counties, US, 1996
| Primary Care | Specialists | All Physicians | |
| Whole County HPSAs |
|
|
|
| Partial County HPSAs |
|
|
|
| Non-HPSAs |
|
|
|
·International medical graduates do constitute a greater percentage
of the US primary care physician workforce in rural, underserved
areas than in rural areas that do not have a physician shortage.
This finding is substantiated in most cases at the national, Census
region, and state scales of analysis.
·There is also substantial interstate variation in the extent
to which IMGs practice in rural, underserved areas. Some states,
such as Mississippi, South Carolina, and Montana, have markedly
higher percentages of IMGs in rural, underserved areas than in
rural areas that do not have a physician shortage. Variation in
geographical distribution vis-à-vis underservice is often much
more apparent at the state scale of analysis than at the regional
or national scales of analysis.
The analysis of IMG location by state raises the issue of the
importance of policy-making at that level. Policies that affect
IMG distribution are varied and complex, and include state policies
toward local recruitment, health workforce planning, policies
toward federally requested exchange visitor visa waivers, administration
of exchange visitor visa waivers, and regulations toward IMG licensure
requirements. Given the complex interweaving of federal, state,
and local policies, there is a strong need for greater collaboration,
coordination, and consistency in policies toward IMGs.
Although state policies may be a key factor in IMG distribution,
it would be an oversimplification to insist that the interstate
variation in IMG distribution indicates that policy or legal issues
are the single most important factors in IMG location, since the
same geographical pattern can occur under other conditions. There
may be many cultural and social factors affecting IMG location
that are revealed at finer geographical scales, and which affect
the state-by-state distribution of IMGs. Among the many possible
reasons why IMGs help alleviate rural underservice more so in
some states than in others include: state policies, state-federal
interaction, social and cultural networks, public perceptions
of the status of IMGs, hospital recruitment efforts and the location
and activity of physician recruiters and lawyers seeking immigration
pathways for clients. This study suggests that local and state
conditions be given consideration in any policy that seeks to
change the supply of IMGs in rural or other underserved areas.