U.S. patients of doctors who went to medical school outside the country and weren’t American citizens had a 9 percent lower death rate on average than those whose doctors trained at home, a study showed.
The report, published today in the August issue of Health Affairs, tracked the performance of primary-care doctors, internists and cardiologists in 244,153 hospitalizations involving congestive heart failure or heart attacks.
Economics may help explain the gap in patient outcomes, said John Norcini, co-author of the study. Internal medicine and primary care have failed to attract the best U.S. students because of lower pay, relative to other specialties, he said.
“Primary care may not be getting the best and the brightest from U.S. medical schools,” said Norcini, chief executive officer of the Foundation for Advancement of International Medical Education and Research, a Philadelphia-based nonprofit. “Foreign students see primary care as a gap that they can fill and a way to practice medicine here.”
Primary-care doctors, including internists and family practice physicians, earn on average from $175,000 to $200,000 annually, while orthopedic surgeons make $519,000; radiologists, $417,000; and anesthesiologists $331,000, according to a survey released in June by the national physician search firm Merritt Hawkins, based in Irving, Texas.
U.S. medical schools don’t produce enough graduates to supply all the postgraduate training slots available, and the void has been filled by graduates from institutions in other countries, Norcini said. These international-schooled doctors make up a quarter of practicing physicians in the U.S., and are especially important in the area of primary care, he said.
‘Cream of the Crop’
“We have been blessed with the cream of the crop” from other countries, said Norcini. “The ones who make it through to become doctors are highly desirable and highly motivated.”
Before being eligible to apply for a post-graduate residency slot in the U.S., graduates of non-U.S. medical schools must go through a two-step process that tests a graduate’s clinical knowledge and skills. Over the past five years, more than 10,000 certificates have been awarded annually by the Educational Commission for Foreign Medical Graduates, the group that created Norcini’s foundation.
The authors of the Health Affairs study said their results, based on data from 2003 to 2006 in Pennsylvania, mark a shift from the early 1990s when research showed international medical graduates underperforming U.S.-trained doctors on licensing examinations, specialty board certifications and other metrics.
“I am somewhat surprised by the results of the study,” said John Prescott, chief academic officer of the American Association of Medical Colleges in Washington. “But the paper was well-written and the authors went out of their way to address any issues people might raise.”
Not all international medical graduates had good results. U.S. citizens who attended medical schools abroad underperformed graduates of U.S. medical schools and citizens from other countries who went to school outside the U.S. Internationally trained foreign doctors had a 16 percent lower mortality rate than Americans schooled overseas, according to the Health Affairs article.
“Whenever you have a study like this, it says perhaps we need to look a little more closely,” AAMC’s Prescott said.
Harlan Krumholz, a professor at Yale School of Medicine and director of Yale-New Haven Hospital Center for Outcomes Research and Evaluation, raised issues with the methodology and conclusions of the study.
“In reality there is a team of doctors for every patient and it is difficult to know the role that any one individual played,” he said in an e-mail. He also questioned why the article didn’t distinguish where the international medical graduates went to school.
“This can only be considered an exploratory result,” he said.
Even though foreign medical graduates produced good patient outcomes, according to this study, they may find it harder to get a post-graduate residency as U.S. medical schools have increased their class sizes while the federal government has failed to raise the number of training spots available. The number was capped in 1997 as a way to control spending on Medicare, the U.S. health plan for the elderly and disabled. Medicare helps fund post-graduate positions.
The study also found that doctors who have been certified by a medical specialty board -- typically after completing post-graduate training -- have lower mortality rates than those who haven’t been, regardless of nationality, Norcini said. The further a doctor gets from medical training the worse their patients fare as well, making an argument for the need for continuing education and post-certification testing, he said.
“People don’t need to pay so much attention to whether their doctor is a graduate of an international school but they should pay more attention to whether or not the doctor has been board certified,” Norcini said.