Selection of international medical graduates into postgraduate training positions in Canada. Who applies? Who is selected?

Background: International medical graduates (IMGs) are an essential part of the Canadian physician workforce. Considering current pressures on the health care system, an update regarding application numbers and match rates for IMGs to postgraduate positions in Canada is needed. Methods: We conducted a quantitative cross-sectional study to explore the characteristics of IMGs who are currently applying to the Canadian Residency Matching Service (CaRMS) positions to gain a broad understanding of the composition of this group and the factors associated with successful matching. Results: Out of 1,725 applicants in 2019, 14.1% matched on the first attempt and 6.4% after two to three attempts. Only 22.7% matched with a position (57.6% women). Applicants submitted an average 19.6 site/program applications. The percentage of IMGs matched did not statistically differ by gender. The relationship between the year of graduation or geographic area of medical school qualified and matching was significant for the first and second iterations, with current-year graduates and Oceania/Pacific Islands applicants more likely to match. Conclusions: This study provided us with accurate numbers and information about the Canadians studying abroad and IMG groups applying, and factors associated with being matched to the IMG positions through CaRMS, which will be instrumental in informing future selection implications for Canada.

Contexte: Les diplômés hors du Canada et des États-Unis (DHCEU) constituent un élément essentiel de la main-d'œuvre médicale au Canada. Compte tenu des pressions qui s'exercent actuellement sur le système de santé, il est nécessaire de faire le point sur le nombre de candidatures et les taux de jumelage des DHCEU à des postes de résidence au Canada. Méthodes: Nous avons mené une étude quantitative transversale pour explorer les caractéristiques des DHCEU qui postulent actuellement aux postes du Service canadien de jumelage des résidents (CaRMS) afin de mieux comprendre la composition de ce groupe et les facteurs associés à un jumelage réussi. Résultats: Sur 1 725 candidats en 2019, 14,1 % ont été jumelés dès leur première tentative et 6,4 % après 2 ou 3 tentatives. Seulement 22,7 % des candidats ont obtenu un poste (57,6 % de femmes). En moyenne, les candidats ont soumis des demandes à 19,6 endroits/programmes. Le pourcentage de DHCEU jumelés n'était pas statistiquement différent selon le sexe. La relation entre l'année d'obtention du diplôme ou la zone géographique de la faculté de médecine où il avait été obtenu et le jumelage était significative pour le premier et le deuxième tours, les diplômés de l'année en cours et les candidats de l'Océanie/îles du Pacifique étant plus susceptibles d'être jumelés. Conclusions: Cette étude nous a fourni des chiffres et des renseignements précis sur les Canadiens qui étudient à l'étranger et les groupes de DHCEU qui posent leur candidature aux postes destinés aux DHCEU dans le cadre du CaRMS, ainsi que sur les facteurs associés à un jumelage réussi, ce qui contribuera à guider la sélection des futurs candidats au Canada.

[Teaching assistants in Argentina have greater intentions to migrate abroad as physicians than other medical students] / Los ayudantes de cátedra en Argentina tienen mayores intenciones de migrar al extranjero como médicos que otros estudiantes de Medicina.

Introduction: The brain drain of physicians from lower-middle-income countries to high-income countries is a growing phenomenon that contributes to global health inequalities. Retention strategies are difficult to implement locally and to specifically target the population at risk of migrating. We hypothesize that medical students who are teaching assistants have greater intentions to migrate to practice Medicine abroad. Methods: Medical students from Argentina were invited to an online survey of 22 multiple-choice questions based on the LIRHUS Network survey, previously used in Latin America. Results: 2,301 medical students were enrolled. Most were young (23 [20-25] years old), single (90%), and female (79%). The majority studied at public universities (87%). The intention to migrate to practice Medicine abroad was more frequent among teaching assistants (36% vs 31%; χ2 = 4.4982; p = 0.0339). After adjusting for sex and age, being a teaching assistant was associated with the intention to migrate to practice Medicine abroad (OR = 1.26; 95% CI 1.02 - 1.55; p = 0.002). Conclusions: Argentine teaching assistants have a greater risk of migrating to practice Medicine abroad. Given their high academic profile, these are valuable human resources trained using the public financing of low-middle-income countries. The loss of these resources could contribute to health inequalities. This is an easily identifiable and accessible subgroup toward which local retention policies could be directed.

Introducción: La fuga de cerebros de médicos de países de ingresos medianos- bajos a países de ingresos altos es un fenómeno creciente que contribuye a las desigualdades mundiales en salud. Las estrategias de retención son difíciles de implementar localmente y de dirigir específicamente a la población en riesgo de migrar. Hipotetizamos que los estudiantes de Medicina que son ayudantes tienen mayores intenciones de migrar para ejercer la Medicina en el extranjero. Métodos: Estudiantes de Medicina de Argentina fueron invitados a una encuesta online de 22 preguntas de opción múltiple basada en la encuesta de la Red LIRHUS, previamente utilizada en América Latina. Resultados: Se enrolaron 2.301 estudiantes de Medicina. La mayoría eran jóvenes (23 [20-25] años), solteras (90%) y mujeres (79%). La mayoría estudiaba en universidades públicas (87%). La intención de migrar para ejercer la Medicina en el extranjero fue más frecuente entre los ayudantes (36% vs 31%; χ2 = 4,4982; p = 0,0339). Después de ajustar por sexo y edad, ser ayudante se asoció con la intención de migrar para ejercer la Medicina (OR = 1,26; IC 95% 1,02 - 1,55; p = 0,002). Conclusiones: Los ayudantes argentinos tienen mayor riesgo de migrar para ejercer la Medicina en el exterior. Dado su alto perfil académico, se trata de recursos humanos valiosos formados con la financiación pública de un país de ingresos medianos-bajos, cuya pérdida puede contribuir a las desigualdades en salud. Es un subgrupo fácilmente identificable y accesible hacia el que se pueden dirigir políticas de retención locales.

Migration and professional mobility: Rural attraction and retention of South African educated physicians.

Rural communities in Alberta, Canada have faced physician shortages for decades. Attracting internationally educated physicians, including many South African physicians, is one way to address this problem. While much of the research on international medical graduates (IMGs) focuses on the push and pull of attraction and retention, I situate the decision to stay as a matter of geographic and professional mobility, all within a life course perspective. More specifically, I explore physicians' decisions to migrate from South Africa to rural Alberta and the impact of professional mobility on their migrations. To understand the processes, I collected data via semi-structured virtual interviews with 29 South African educated generalist/family physicians with experience in rural Alberta. Research was guided by abductive grounded theory and data was analysed using open thematic coding. I found that South African educated physicians made the decision to leave South Africa and to come to Canada to pursue prestige and opportunity they perceived to be inaccessible in South Africa. However, physicians were limited to perceived low prestige work as rural generalists, while they understood that more prestigious work was reserved for Canadian educated physicians. Physicians who remained in rural communities brought their aspirations to life, or achieved upward professional mobility in rural communities, through focused clinical and administrative opportunities. The decision to leave rural communities was often a matter of lifestyle and burnout over prestige.

DO seniors and IMGs have lower match probabilities than MD seniors after adjusting for specialty choice and USMLE Step 1 score.

CONTEXT: It is unknown if US residency applicants of different educational backgrounds (US allopathic [MD], Doctor of Osteopathic Medicine [DO], and international medical graduates [IMG]) but comparable academic performance have similar match success. OBJECTIVES: Our objective was to compare match probabilities between applicant types after adjusting for specialty choice and United States Medical Licensing Examination (USMLE) Step 1 scores. METHODS: We performed a secondary analysis of published data in National Resident Matching Program (NRMP) reports from 2016, 2018, 2020, and 2022 for US MD seniors, DO seniors, and IMGs (US citizens and non-US citizens). We examined the 10 specialties with the most available spots in 2022. Average marginal effects from a multiple variable logistic regression model were utilized to estimate each non-MD senior applicant type's probability of matching into their preferred specialty compared to MD seniors adjusting for specialty choice, Step 1 score, and match year. RESULTS: Each non-MD applicant type had a lower adjusted percent difference in matching to their preferred specialty than MD seniors, -7.1 % (95 % confidence interval [CI], -11.3 to -2.9) for DO seniors, -45.6 % (-50.6 to -40.5) for US IMGs, and -56.6 % (-61.5 to -51.6) for non-US IMGs. Similarly, each non-MD applicant type had a lower adjusted percent difference in matching than MD seniors across almost all Step 1 score ranges, except for DO seniors with Step 1 scores <200 (-2.0 % [-9.5 to 5.5]). CONCLUSIONS: After adjusting for specialty choice, Step 1 score, and match year, non-US MD applicants had lower probabilities of matching into their preferred specialties than their US MD colleagues.

Analysis of Performance Trends from 2010-2019 on the American Board of Internal Medicine Nephrology Certifying Exam.

BACKGROUND: The pass rate on the American Board of Internal Medicine (ABIM) nephrology certifying exam has declined and is among the lowest of all internal medicine (IM) subspecialties. In recent years, there have also been fewer applicants for the nephrology fellowship match. METHODS: This retrospective observational study assessed how changes between 2010 and 2019 in characteristics of 4094 graduates of US ACGME-accredited nephrology fellowship programs taking the ABIM nephrology certifying exam for the first time, and how characteristics of their fellowship programs were associated with exam performance. The primary outcome measure was performance on the nephrology certifying exam. Fellowship program pass rates over the decade were also studied. RESULTS: Lower IM certifying exam score, older age, female sex, international medical graduate (IMG) status, and having trained at a smaller nephrology fellowship program were associated with poorer nephrology certifying exam performance. The mean IM certifying exam percentile score among those who subsequently took the nephrology certifying exam decreased from 56.7 (SD, 27.9) to 46.1 (SD, 28.7) from 2010 to 2019. When examining individuals with comparable IM certifying exam performance, IMGs performed less well than United States medical graduates (USMGs) on the nephrology certifying exam. In 2019, only 57% of nephrology fellowship programs had aggregate 3-year certifying exam pass rates ≥80% among their graduates. CONCLUSIONS: Changes in IM certifying exam performance, certain trainee demographics, and poorer performance among those from smaller fellowship programs explain much of the decline in nephrology certifying exam performance. IM certifying exam performance was the dominant determinant.

Academic Productivity of United States Neurosurgeons Trained Abroad.

BACKGROUND: Previous research in neurosurgery has examined academic productivity for U.S. medical graduates and residents. However, associations between scholarly output and international medical education, residency training, and fellowship training are scarcely documented. METHODS: We identified 1671 U.S. academic neurosurgeons in 2020 using publicly available data along with their countries of medical school, residency, and fellowship training. Using Scopus, h-index, number of publications, and number of times publications were cited were compiled. Demographic, subspeciality, and academic productivity variables were compared between training locations using univariate analysis and multivariable linear regression. RESULTS: Of the current neurosurgery faculty workforce, 16% completed at least 1 component of their training abroad. Canada was the most represented international country in the cohort. Academic productivity for neurosurgeons with international medical school and/or international residency did not significantly differ from that of neurosurgeons trained in the United States. Neurosurgeons with ≥1 U.S. fellowships or ≥1 international fellowships did not have higher academic productivity than neurosurgeons without a fellowship. However, dual fellowship training in both domestic and international programs was associated with higher mean h-index (ß = 6.00, 95% confidence interval 1.01 to 10.98, P = 0.02), higher citations (ß = 2092.0, 95% confidence interval 460.1 to 3724.0, P = 0.01), and a trend toward higher publications (ß = 36.82, 95% confidence interval -0.21 to 73.85, P = 0.051). CONCLUSIONS: Neurosurgeon scholarly output was not significantly affected by international training in medical school or residency. Dual fellowship training in both a domestic and an international program was associated with higher academic productivity.

Medical School Accreditation Factors Associated With Certification by the Educational Commission for Foreign Medical Graduates (ECFMG): A 10-Year International Study.

PURPOSE: In 2024, international medical graduates seeking Educational Commission for Foreign Medical Graduates (ECFMG) certification will be required to graduate from an accredited medical school. This study's goal was to examine relationships between medical school accreditation variables and ECFMG certification for a global sample. METHOD: Using ECFMG databases, the authors created a 10-year cohort (January 1, 2007-December 31, 2016) of certification applicants, defined as individuals who had attempted at least 2 examinations required for certification. The authors aggregated applicant data at the school level, excluding schools with < 80 applicants. School accreditation statuses were based on agency websites. School region, age, and time of first accreditation were included. Analyses included descriptive and bivariate statistics and multiple linear regressions adjusting for school start year and year of first accreditation. RESULTS: The cohort included 128,046 applicants from 1,973 medical schools across 162 countries. After excluding low-volume schools, 318 schools across 81 countries remained. These provided 99,598 applicants and 77,919 certificate holders, three-quarters of whom came from the Caribbean, South-Central Asia, and West Asia regions. Two hundred and fifty (78.6%) schools were accredited; 68 (21.4%) were not. Most ECFMG applicants (n = 84,776, 85.1%) and certificate holders (n = 68,444, 87.8%) attended accredited medical schools. Accredited schools had higher rates of ECFMG certification among graduates than nonaccredited schools in comparisons that included all schools (75.0% [standard deviation (SD) = 10.6%] vs 68.3% (SD = 15.9%), P < .001), and for countries that had both accredited and nonaccredited schools (73.9% [SD = 11.4%] vs 67.3% [SD = 16.8%], P = .023). After adjusting for age of school, longer duration of accreditation was associated with higher certification rates (P < .001). CONCLUSIONS: Accreditation had a positive association with ECFMG certification rates. Future studies should investigate how accreditation processes might account for higher certification rates.

Trends in the research profile of matched independent plastic surgery fellows.

ABSTRACT: The independent plastic surgery pathway recruits candidates with 5 years of surgical training who are typically more advanced in research than their integrated counterparts. Research productivity helps to discriminate between applicants. However, no studies exist detailing the academic attributes of matched independent plastic surgery candidates.We performed a cohort study of 161 independent plastic surgery fellows from accredited residency programs from the 2015 to 2017 application cycles. We performed a bibliometric analysis utilizing Scopus, PubMed, and Google Scholar to identify research output measures at the time of application.The cohort was predominantly men (66%) with a median of 3 articles and a H-index of 1 at the time of application. Interestingly, 16% of successful candidates had no published articles at the time of application, and this did not change significantly over time (P = .0740). Although the H-index remained stable (R 0.13, P = .1095), the number of published journal articles per candidate significantly decreased over 3 consecutive application cycles (R -0.16, P = .0484). Analysis of article types demonstrated a significant increase in basic science articles (R 0.18, P = .0366) and a concurrent decrease in editorial-type publications (R = -0.18, P = .0374).Despite the decline in publication volume of matched independent plastic surgery fellows, the quality of their research portfolio has remained constant. Matched applicants appear to be shifting focus from faster-to-publish articles to longer but higher impact projects. In selecting a training route, applicants must weigh the highly competitive integrated path against the dwindling number of independent positions.

International Medical Graduates are Comparable to American Medical Graduates as General Surgery Interns.

BACKGROUND: International medical graduates (IMGs) are often relegated to preliminary positions in general surgery (GS) owing to uncertainties about the candidate's performance in the American healthcare setting. We aimed to determine the comparative performance of IMGs and American medical graduates (AMGs) at baseline and assess these trends over the course of their GS internship. METHODS: Evaluations of all IMG preliminary and AMG categorical interns from 2013 to 2017 at our GS residency program were obtained from three faculty members to score overall performance, technical skills, interpersonal communication, and medical knowledge on a 10-point Likert scale. Scores on the American Board of Surgery In-Training Exam, an in-house preparation test, United States Medical Licensing Exam, and performance during the biannual multistation objective assessments were compared between the two resident groups. RESULTS: Seventy-two interns (28 [39%] AMG categorical and 44 [61%] IMG preliminary) met inclusion criteria. The AMG group had significantly higher median Step 1 and Step 2 scores compared with our IMG group (243 versus 231, P = 0.002, and 250 versus 246, P = 0.03, respectively).Although in-house preparation test scores were higher among IMGs (median [interquartile range] of 36 [33-40] among AMGs and 38 [34-45] among IMGs; P = 0.002), there were no statistically significant differences between the American Board of Surgery In-Training Exam scores of the two groups. The median scores for the four faculty evaluation components were similar between the AMG (7, 8, 7, 7) and IMG resident groups (7, 7, 7, 7; P = nonsignificant). IMGs scored significantly higher in both biannual multistation objective assessments than AMGs (median [interquartile range] July: 59 [47-91] versus 55 [37-62], P = 0.005; January: 103 [86-116] versus 91 [87-104], P = 0.03). CONCLUSIONS: It is reassuring to confirm that no matter where they are from, great candidates can perform well as surgical interns in a GS training program.

Doctor Retention or Migration: From Ireland to the World? Comment on "Doctor Retention: A Cross-sectional Study of How Ireland Has Been Losing the Battle".

The recent study of prospective doctor migration and retention suggests that more than half of junior doctors intend to migrate from Ireland. While intent is not necessarily outcome, such intentions match similar survey results in Ireland and elsewhere. The rationale for migration is described as a function of difficult workplace circumstances (notably long hours and mismanagement). Lifestyle factors may however also be important for both migration and significant levels of return migration. These are related to family formation, and to an established culture of migration, that has contributed to a considerable circularity of mobility and migration, primarily between Anglophone countries. International migration may also have unspecified regional variations and impacts. Migration has taken a similar form for half a century and longstanding policies to constrain its more damaging impacts have been conspicuously unsuccessful yet responses remain urgent.

What influences trainee decisions to practise in rural and regional Australia?

Although international medical graduates (IMGs) make up a substantial part of the Australian rural general practice workforce, most research on factors associated with rural practice has focused on Australian medical graduates (AMGs). This study aimed to determine whether there were differences between IMGs and AMGs in terms of these factors. Registrars in training and recent fellows (Fellowship of the Royal Australian College of General Practitioners/Fellowship of the Australian College of Rural and Remote Medicine) who participated in training in rural and regional Australia were surveyed about practice models and rural practice. Almost two-thirds of participants were practicing or intending to practice in rural areas, with no difference between AMGs and IMGs. None of the variables associated with rural practice for AMGs was found to be associated with rural practice in IMGs in univariate binary regression analysis. Two key variables that are strongly associated with rural medical practice in the current literature, namely rural background and rural exposure, were not significant predictors of rural practice among IMGs. Due to the significant number of IMGs in regional training programs, any future incentives designed to improve rural recruitment and retention need to address factors relevant to IMGs.

Health professional mobility in the WHO European Region and the WHO Global Code of Practice: data from the joint OECD/EUROSTAT/WHO-Europe questionnaire.

WHO Member States adopted the Global Code of Practice on the International Recruitment of Health Personnel 10 years ago. This study assesses adherence with the Code's principles and its continuing relevance in the WHO Europe region with regards to international recruitment of health workers. Data from the joint OECD/EUROSTAT/WHO-Europe questionnaire from 2010 to 2018 are analyzed to determine trends in intra- and inter-regional mobility of foreign-trained doctors and nurses working in case study destination countries in Europe. In 2018, foreign-trained doctors and nurses comprised over a quarter of the physician workforce and 5% of the nursing workforce in five of eight and four of five case study countries, respectively. Since 2010, the proportion of foreign-trained nurses and doctors has risen faster than domestically trained professionals, with increased mobility driven by rising East-West and South-North intra-European migration, especially within the European Union. The number of nurses trained in developing countries but practising in case study countries declined by 26%. Although the number of doctors increased by 27%, this was driven by arrivals from countries experiencing conflict and volatility, suggesting countries generally are increasingly adhering to the Code's principles on ethical recruitment. To support ethical recruitment practices and sustainable workforce development in the region, data collection and monitoring on health worker mobility should be improved.

Resident Physician Prescribing Variability Demonstrates Need for Antimicrobial Stewardship in Continuity Clinic: A Pilot Study.

BACKGROUND: Inappropriate antimicrobial use is common in the outpatient setting but often goes unaddressed by stewardship education. Residents might benefit from directed stewardship education. OBJECTIVE: We conducted a needs assessment of resident knowledge, attitudes, and behaviors regarding antibiotic use and stewardship in outpatient continuity clinics. METHODS: Internal medicine (IM) residents with continuity clinic at Minneapolis Veterans Affairs Health Care System were eligible. Antimicrobial prescriptions and number of visits were extracted from the Computerized Patient Record System (July 1, 2017-March 31, 2018). Antimicrobial rate (prescriptions per 1000 visits) was calculated for each resident. Results from a resident survey that included demographics, attitudes, and case-based multiple-choice knowledge questions were linked by unique identifier to antimicrobial rate. RESULTS: Prescription and visit data were available for 37 residents. Mean monthly antimicrobial rate was 51 prescriptions per 1000 visits (range 8-239). Surveys were completed by 19 residents (51%). Respondents were 32% female, 32% interns, and 11% international medical graduates. An online resource was most commonly used for prescribing guidance, whereas lectures and small group sessions for residents were rated as the most helpful educational modalities. Many respondents reported being unprepared to perform basic tasks related to antimicrobial stewardship. Median percentage correct was 57% of case-based knowledge questions (interquartile range 50%-71%). CONCLUSIONS: Antimicrobial rates among IM residents at a VA outpatient continuity clinic are low and vary by provider. Residents agree with key antimicrobial stewardship concepts but lack preparation in tasks related to antimicrobial stewardship. Knowledge regarding antimicrobial prescribing was low.

The role of the University of Cape Town, South Africa in the training and retention of surgeons in Sub-Saharan Africa.

BACKGROUND: Sub-Saharan Africa (SSA) has a shortage of surgeon specialists. Many SSA countries lack specialty training programs but South Africa, an upper middle-income country, has several post-graduate surgical training programs. The primary objective of this study was to describe the retention rates of non-South African SSA surgical trainees from the University of Cape Town (UCT) on the African sub-continent. The secondary objective was to describe advantages and disadvantages of foreign surgical trainees on the UCT surgical training programs. METHODS: This was a two-part cross-sectional survey administered via email between June 1, 2018 and March 1, 2019 to UCT 1) surgical residents and fellows who graduated between 2007 and 2017 and whose country of origin was in SSA but outside South Africa, and 2) UCT surgical division heads. RESULTS: Thirty out of 78 (38%) trainees responded; 83% (n = 25) were male. There was a 96% retention rate of surgical trainees in SSA, 80% (n = 24) returned to their country of origin after training, 83% (n = 25) worked in the public sector, and 90% (n = 27) in teaching hospitals. Seven out of ten surgical division heads responded. Reported advantages of SSA trainees included more junior staff (n = 5, 71%) and the establishment of SSA networks (n = 4, 57%). Disadvantages included increased training responsibilities for educators (n = 2, 29%) and fewer cases for South African trainees (n = 2, 29%). DISCUSSION: Retention on the African sub-continent of surgeons who trained at UCT was high. SSA doctors can utilize South African post-graduate surgical training programs until their own countries increase their training capacity. The majority of trainees returned to their countries of origin, utilizing their skills in the public and academic sectors, and contributing to the teaching of more trainees. These training partnerships also contribute to knowledge-sharing and facilitate a regional network of African surgeons. Active recruitment of more female trainees is needed to ensure gender equity.

Egalitarianism in surgical training: let equity prevail.

This study aimed to quantify core surgical trainee (CST) differential attainment (DA) related to three cohorts; white UK graduate (White UKG) versus black and minority ethnic UKG (BME UKG) versus international medical graduates (IMGs). The primary outcome measures were annual review of competence progression (ARCP) outcome, intercollegiate Membership of the Royal College of Surgeons (iMRCS) examination pass and national training number (NTN) selection. Intercollegiate Surgical Curriculum Programme (ISCP) portfolios of 264 consecutive CSTs (2010-2017, 168 white UKG, 66 BME UKG, 30 IMG) from a single UK regional post graduate medical region (Wales) were examined. Data collected prospectively over an 8-year time period was analysed retrospectively. ARCP outcomes were similar irrespective of ethnicity or nationality (ARCP outcome 1, white UKG 60.7% vs BME UKG 62.1% vs IMG 53.3%, p=0.395). iMRCS pass rates for white UKG vs BME UKG vs IMG were 71.4% vs 71.2% vs 50.0% (p=0.042), respectively. NTN success rates for white UKG vs BME UKG vs IMG were 36.9% vs 36.4% vs 6.7% (p=0.023), respectively. On multivariable analysis, operative experience (OR 1.002, 95% CI 1.001 to 1.004, p=0.004), bootcamp attendance (OR 2.615, 95% CI 1.403 to 4.871, p=0.002), and UKG (OR 7.081, 95% CI 1.556 to 32.230, p=0.011), were associated with NTN appointment. Although outcomes related to BME DA were equitable, important DA variation was apparent among IMGs, with iMRCS pass 21.4% lower and NTN success sixfold less likely than UKG. Targeted counter measures are required to let equity prevail in UK CST programmes.