International medical graduates make up a quarter of the physician
workforce in the United States, United Kingdom, Canada, and Australia.
Although international graduates are required to pass examinations to
practice medicine in the UK and US, concerns have been raised about the
quality of care provided by these graduates.
Yet no study has investigated differences in patient outcomes
between international medical graduates and US medical graduates using
nationally representative data.
‘In the United States, patient death rates are lower for internationally trained graduates than for graduates from a US medical school, despite international graduates caring for patients with higher rates of chronic conditions.’
So a team of researchers set out to determine whether patient
outcomes differ between general internists who graduated from a medical
school outside the US and those who graduated from a US medical school.
They analyzed a national sample of data for over 1.2 million
Medicare beneficiaries aged 65 years or older admitted to hospital with a
medical condition in 2011-14 and treated by over 44,000 international
or US medical graduates who were general internists.
The primary outcome was 30 day mortality of patients. Secondary outcomes were 30 day readmission rates and costs of care.
Compared with patients treated by US graduates, patients treated by
international graduates had slightly more chronic conditions.
After adjusting for factors that could have affected the results
(including patient characteristics, physician characteristics, and
hospital fixed effects), they found that patients cared for by
international graduates had a lower risk of mortality (11.2% v 11.6%)
than patients cared for by US graduates across a broad range of clinical
The researchers say that for every 250 patients treated by US
medical graduates, one patient's life would be saved if the quality of
care were equivalent between the international graduates and US
Readmission rates did not differ between the two types of graduates,
whereas costs of care per admission was slightly higher for
international medical graduates ($1145 v $1098). Further analysis to
test the strength of the results made no difference to the overall
One possible explanation, say the authors, is that the current
approach for allowing international medical graduates to practice in the
US may select for, on average, better physicians.
They stress that this is an observational study so no firm
conclusions can be drawn about cause and effect. Nevertheless, they say
their findings "should reassure policymakers and the public that our
current approach to licensing international medical graduates in the US
is sufficiently rigorous to ensure high quality care."