Selim Krim, MD Assistant Professor of Medicine Division Of General Internal medicine Texas Tech University Health Scienc

1. International Medical Graduates: Update on A Diversified Physician Workforce Selim Krim, MDAssistant Professor of MedicineDivision Of General Internal medicineTexas Tech University Health Sciences Center

2. Where I am from

3. Algeria/Location

4. Where I was born

5. Algeria/History 500,000 and 700,000: Homo erectus 10,000 BC: Berbers 1000 BC: Numidia 200 BC: Part of the Western Roman Empire 300 AD:Part of the Byzantine Empire 800 AD:Muslim Arab Armies arrive 1510: Spain takes control 1516: Part of Ottoman Empire 1830: France invades Algeria 1954: Algerian War of Independence 1962: Independence of Algeria

6. Algeria Country Name: People's Democratic Republic of Algeria Government type: Republic Independence:July 5, 1962 Population: 34,178,188 Age:26.6 years (median), 65-0ver represent 5% of total Population Ethnic groups:Arab-Berber 99%, European less than 1% Languages:Arabic, French, Berber Religions:Sunni Muslim (state religion) 97%, Christian and Jewish 3%

7. Algiers The White

9. Our Lady of Africa

10. Our Lady of Africa

11. Ketchaoua Mosque

16. My Journey Paris Lubbock Pittsburgh Algiers

17. International Medical Graduates

18. DefinitionsIMGs are physicians who have completed their medical education outside the U.S. or Canada. IMGs consist of:Foreign nationals on special visa status (eg. J1 or H1B) U.S. citizens or permanent residents who graduated from foreign medical schools

19. Where are they coming from? Zoghbi, W. A. et al. J Am CollCardiol 2004;44:245-251

20. The Educational Commission for Foreign Medical Graduates (ECFMG) “ Through its program of certification, the Educational Commission for Foreign Medical Graduates (ECFMG®) assesses the readiness of international medical graduates to enter residency or fellowship programs in the United States that are accredited by the Accreditation Council for Graduate Medical Education (ACGME).”

21. ECFMG Certification Pass the USMLE: Medical Science Examination Step 1 Clinical Skills Assessment Step2 (CS) Clinical Knowledge Assessment Step2 Must pass all exams within a 7 year period! ECFMG Verification of medical diploma with medical school

22. The NRMP “Match” • The National Resident Matching Program (NRMP) is a private, not-for-profit corporation established in 1952 to provide a uniform date of appointment to positions in graduate medical education (GME). • Each year, the NRMP conducts a residency match that is designed to optimize the rank ordered choices of students and program directors.

23. How many IMGs Apply for PGY1 position? U.S. NRMP, Match results. 2007

24. How many IMGs Obtain a PGY1 Position? U.S. NRMP, Match results. 2007

25. Challenges

26. Costs • The USMLE: • Medical Science Examination Step 1= $ 710 • Clinical Skills Assessment (Step2 CS)= $ 1200 • Clinical Knowledge Assessment (Step2 CK)= $ 710 • Interviews and travel: • Program Applications: $ 2000 • Cost of travel for step2 CS: $1000-$2000

27. Visas • Immigration Laws • Can affect training of IMGs and chances of joining the workforce • Increasingly pose obstacles for international travel for IMGs and their families • Employment • Primarily related to visa status • J-1 visa holders are at increasing risk of not finding waivers, particularly after Sept. 11th

28. Visas (Non-Clinical Visa Programs) • J-1 Research- 5 years maximum potential duration (Caution: 2-year rule may be attached) • H-1B – 6 years maximum duration • NAFTA – Canadian & Mexican nationals only • Universities, medical schools and research • institutions may offer visa assistance for • research activities

29. Visas(Visa Programs for Clinical Training) • J-1 ECFMG (Educational Commission for Foreign Medical Graduates) - 7 years maximum potential duration Caution: 2-year home rule is attached. • H-1B – 6 years maximum durationRequires all 3 Steps of USMLE

30. Country of Medical School Distribution Patterns of Origins and Destinations Demographic Characteristics http://www.fammed.washington.edu/CHWS/

31. http://www.fammed.washington.edu/CHWS/

32. Distribution of IMGs in The U.S. in 2001, by County http://www.fammed.washington.edu/CHWS/

33. http://www.fammed.washington.edu/CHWS/

34. http://www.fammed.washington.edu/CHWS/

35. Who are the patients of international medical graduates? • Race/Ethnicity • Expected source of payment • Characteristics of patient’s neighborhoods • Who are international medical graduates? • Where do international medical graduates practice?

36. NCHS Data Brief ■ No. 13 ■ February 2009 Office visits by Patients Race\Ethnicity NCHS Data Brief ■ No. 13 ■ February 2009

37. Office visits by patients’ primary Expected sources of payment NCHS Data Brief ■ No. 13 ■ February 2009

38. Characteristics of patient’s neighborhoods NCHS Data Brief ■ No. 13 ■ February 2009

39. IMG vs. USMG By Race/Ethnicity NCHS Data Brief ■ No. 13 ■ February 2009

40. Where do IMG they practice? NCHS Data Brief ■ No. 13 ■ February 2009

41. The purpose of this pilot project was to assess IMG perceptions in two major policy areas: (a) IMG impact on U.S. healthcare (b) IMG impact on countries of origin

42. Impact on U.S. healthcare S. Agrawal. OPUS 12 Scientist 2008 Vol. 2, No. 1

43. Impact on Countries of Origin S. Agrawal. OPUS 12 Scientist 2008 Vol. 2, No. 1

44. Impact on Countries of Origin S. Agrawal. OPUS 12 Scientist 2008 Vol. 2, No. 1

45. Conclusion • IMGs represent about a quarter of the entire physician workforce • India, the Philippines, Mexico and the Republic of Korea • remain the leading countries of origin of IMGs • There have been consistent patterns of IMG origin countries • and destination states • International medical graduates are more likely to practice • in primary care shortage areas • They are also more likely to have more Medicaid patients and • minorities

46. Conclusion • U.S. health care system continues to rely on international medical graduates to address primary care physician shortage outside of urban metropolitan statistical areas • However our system may face challenges if the future supply and use of international medical graduates are affected by changes in visa policy and other programs affecting physician supply • New policies may be needed in the future

47. International Leaders Salim Yusuf, MD India Huda Zoghbi, MD Lebanon Elias Zerhouni, MD Algeria Andreas Gruntzig, MD Germany Valentine Fuster, MD, PhD Spain

48. “Share our similarities,celebrate our differences” M. Scott Peck, MD

49. Thank you