Evaluating The Quality Of Care Provided By Graduates Of International Medical Schools

In this observational study, we examined whether there were differences in outcomes for patients of international medical school graduates—both non–U.S. citizens and U.S. citizens—versus outcomes for patients of U.S. medical school graduates. We found no difference in mortality when comparing all international medical graduates with U.S. graduates. This is consistent with work done in Canada comparing international graduates and Canadian graduates.¹⁶ Moreover, it speaks to the reliability of the U.S. certification process for international medical graduates.

We also found that there were fewer in-hospital deaths among the patients of non-U.S.-citizen international graduates than was the case for patients of either U.S.-citizen international graduates or U.S. graduates. The difference between non-U.S.-citizen and U.S.-citizen international graduates was striking. Although this finding may be unique, it is not surprising, given previous research. U.S.-citizen international graduates have lower scores on the cognitive portions of the licensing examination sequence, lower ratings from training program directors, and lower rates of specialty board certification.^7,9–12

Part of this performance difference may be due to variability in the quality of the medical schools that U.S.-citizen international graduates attend, but to some degree, it may also reflect their ability.^8,26 It will be important to monitor this possibility, since the pool of U.S. applicants to international schools is a potential source of students for U.S. medical schools as they expand.⁵

We also compared lengths-of-stay among the groups in this study. We found that the patients of international graduates had longer hospitalizations than those of U.S. graduates, although the practical significance of the difference is relatively small. Consistent with previous work, we found that lengths-of-stay were longer for patients of physicians who were further from graduation and shorter for patients of cardiologists and physicians with specialty board certification.^18,19

It is reassuring that international graduates are comparable to U.S. graduates in terms of patient mortality, because they constitute nearly a quarter of the physicians in the United States. These findings are particularly important at a time when there is an impending shortage of physicians in the United States, and international graduates are one way of addressing the shortfall.^4,5

Among international graduates, the apparent superior performance of non–U.S. citizens suggests that policies that affect the size of this group might have implications for quality. Our data also address some of the negative perceptions about the care provided by these physicians.^6,16

In contrast, the apparent performance of U.S. citizens who graduate from international medical schools suggests the importance of further research to clarify whether their performance is a result of their medical education experiences or their ability. To the degree that it is the former, U.S. citizens will need information about international medical schools on which to base their application decisions. To the degree that it is the latter, and as additional training opportunities become available for U.S. citizens, medical schools and residency programs will need to be more vigilant in their selection procedures and not accept students who lack the ability to perform as physicians.