There has been a long and interconnected history between PAs and international medical graduates (IMGs). Some episodes of this history include IMGs' attempts to seek entry to the PA profession by shortcutting the established qualifying and licensing channels. IMGs also have faced difficult challenges in entering U.S. medical practice and in particular U.S. graduate medical education. These physicians already face a tough and expensive gauntlet of certifying organizations, professional tests and government background checks to secure work papers and permanent residency. Those restrictions have only tightened since 9/11, and now some believe the process will become more difficult after the attempted terrorist bombings in Great Britain that have been linked to foreign physicians.
The most recent connection between IMGs and the PA profession is Canada's plan to recruit IMGs as part of its approach to training PAs for practice in that country. The province of Ontario believes that it makes sense to include IMGs among those who enter the formal PA educational programs being developed there, and that this reflects an enlightened social policy toward IMGs who otherwise might not be able to work in medical care delivery.
IMGs and Underserved Americans
It has become more difficult for IMGs to enter U.S. medicine and medical education. The number of physicians in training with J-1 visa waivers (which IMGs must possess) has fallen by almost half over the past decade, from 11,600 in academic year 1996-1997 to fewer than 6,200 in 2004-2005, according to the Government Accountability Office. And federal and state requests for J-1s for physicians dropped from 1,374 in 1995 to 1,012 in 2005. Over each of the past three years, about 1,000 practicing physicians have come to the United States on J-1 visa waivers. Many of them are from unstable or undeveloped countries and come here in search of better training, working conditions and pay. 1
However, since 9/11, the federal government has made it more difficult for IMGs to qualify for the special visas and to obtain permanent residency. The tests are more difficult, the legal fees are higher and the Department of Health and Human Services has changed the rules in such a way that fewer counties and clinics are designated as underserved and thus eligible to obtain J-1 doctors. This had led to shortages of physicians in rural areas and has hampered access to medical care in many rural communities.
In the past, PAs have taken a dim view of IMGs attempting to become PAs, particularly when they attempt either to obtain advanced placement in a PA program or to try to short-circuit codified steps to PA licensure. To address the issue of unlicensed IMGs, some states enacted legislation that funded so-called "fast-track" educational programs to recruit and matriculate IMGs into PA programs. 2 In such instances, IMGs' clinical skills were assessed and compared with those of second-year PA students and found to be nonequivalent. While these experimental tracks in PA programs never became well established, it is upon that basis that many in the PA profession hold that IMGs are inferior in their skills and medical knowledge compared with PA students.
All IMGs Are Not Equal
Nearly all PAs have had extensive contact with IMGs. They make up a considerable part of the medical workforce in several large industrialized nations. IMGs constitute between 23% and 28% of physicians in the United States, the United Kingdom, Canada and Australia, and lower-income countries supply between 40% and 75% of these IMGs. 3
It is a risky proposition to generalize about IMGs and even further to speak definitively about the educational equivalence of PAs versus IMGs. The Harlem Hospital/CUNY "experiment" 2 was a very shaky tidbit of evidence to put forth in support of the notion that IMGs are incompetent relative to second-year PA students (which was the comparison used). This study was a small one-time observation of a selected sample of IMGs, it had weak internal and external validity, and it was never published in the peer-reviewed literature. Thus, we should hesitate to use it as evidence of the "incompetence" of IMGs. 2 A physician who is an IMG, for example, heads the National Institutes of Health. 4
We should be clearly aware of the fact that IMGs represent a very heterogeneous group of physicians, some very well prepared and some not. It is not fair to paint them with a single brush. Canada, in its effort to build its PA profession, decided that IMGs would make very appropriate PA trainees. I suspect that most of these candidates will make fine PAs and will be appropriately socialized to their dependent role. Also, quite a number of PAs were once IMGs who underwent PA education in the United States, passed the PANCE and have had successful PA careers.
The IMG Role
The PA profession has sometimes been quick to condemn the capabilities of IMGs, who often do not have organizations to speak on their behalf or to reply to criticisms. Even as we face external threats such as international terrorism, we should be careful not to veer carelessly into xenophobia. We also should be careful about generalizing about the IMG-PA comparison, particularly when the existing literature on the topic is far from conclusive.
Finally, we should recognize that IMGs have become an important component of the health workforce, particularly in serving in rural communities, and bear in mind that not so long ago, this was felt to be one of the key social mandates for the PA profession.
James F. Cawley is professor and interim director of the PA program at the School of Medicine and Health Sciences at The George Washington University in Washington.
1. Talbott C. Shortage of doctors affects rural U.S. The Washington Post. June 22, 2007.
2. Fowkes V, Cawley JF, Herlihy N, Cuadrado R. Evaluating the potential of international medical graduates as physician assistants in primary care. Acad Med. 1996;71:886-892.
3. Mullan F. The metrics of the physician brain drain. N Engl J Med. 2005;353:1810-1818.
4. Zerhouni EA. International medical graduates in the United States: a view from an ECFMG certificant. Acad Med. 2006;81:S40-S42.