IMG externships: Career investment

International medical graduates find having U.S. clinical experience critical for landing residencies.

By Myrle Croasdale — Posted March 26, 2007

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Dr. Greg Tampus graduated from medical school in the Philippines before he and his wife moved to the United States four years ago.

His wife found a job here as a nurse, but when Dr. Tampus tried to pursue his medical career, he failed to get a residency. During his interviews, each program director asked him the same thing.

"They'd ask for a year's clinical experience, so I knew I had to get that," Dr. Tampus said.

For international medical graduates such as Dr. Tampus, getting clinical experience and letters of recommendation in the United States can mean the difference between becoming a practicing physician or not.

With the number of IMGs seeking U.S. residencies rising and the number of positions almost unchanged, competition is fierce. As a result, more IMGs are seeking to get an edge with externship experience, prompting the emergence of companies offering this service for a fee, a service that until now has been offered free through a hodgepodge of physician organizations and hospitals.

Dr. Tampus, desperate to succeed, paid a firm $1,200 a month for his externships. Web sites for these companies encourage IMGs to sign on for three to six months.

Physician leaders are hesitant to say how much is too much for this service, but many would like to see externships remain a nonprofit effort.

Gamini S. Soori, MD, an oncologist-hematologist in Nebraska, is a member of the American Medical Association's IMG Section, which is working to develop guidelines to standardize externship training.

The adoption of such standards would be voluntary. No single organization oversees externships or observerships. The quality of the experience varies widely, and there is no set duration. Generally, they are at least one month long. Dr. Tampus invested in 11 months.

Speaking on his own behalf, Dr. Soori said he would like to see medical societies develop a network of physician volunteers to oversee externships, an effort he hopes his section's work will jump-start.

He was diplomatic regarding for-profit ventures. "It's not necessarily a bad thing as long as it's done in an ethical way and people are getting what they are paying for," Dr. Soori said. "It's always an area where IMGs could be exploited."

Maryland internist Charu Patel Mehta, MD, who owns one of these externship companies, FMG Affordable, said she shares Dr. Soori's concern. An international medical graduate herself, Dr. Mehta believes she is helping IMGs by providing rigorous training for a price lower than her competitors.

Barry Mehta, her husband and FMG Affordable's director, said most of the $1,000-per-month tuition externs pay goes to the teaching physicians for their time, while additional rent and transportation fees cover exactly that.

"We did not do this with the intent of making a profit," Mehta said.

Is it ethical to pay physicians for their teaching time under these circumstances? Dr. Mehta thinks so, and in academic medicine there is a movement to compensate physicians for clinical teaching.

FMG Portal, based in Atlanta, provides externships in 30 cities and pays its teaching physicians. FMG America, which did not provide information on its size, does not.

Another concern, especially if IMGs are paying, is whether they get adequate training.

Dr. Soori said this was one reason behind the AMA IMG Section's efforts to develop guidelines.

"Anything we can do to improve the standards of IMGs entering residency programs would be a good thing for IMGs and programs themselves," Dr. Soori said. "We want to enhance their success in residency."

Dr. Tampus can attest to externships' variability. He was in the midst of one in Baltimore when he met Dr. Mehta. He asked her to consider supervising him in an externship.

She took his suggestion and went one step further, creating FMG Affordable. Dr. Tampus was her first client.

After rounds with a head trauma surgeon, Dr. Tampus said he was exposed to cases he had only read about. "It was awesome," he said.

Dr. Mehta has two other internists, a pediatrician, a psychiatrist and another surgeon who help train IMGs.

The demand for externships is strong. In 2006, the Educational Commission for Foreign Medical Graduates reported 18,109 IMG registrations for the clinical skills exam -- the last requirement before applying for the National Residency Matching Program. In 2005, there were 16,443 IMG registrants and in 2004, 11,636.

An estimated 6,000 to 7,000 of these IMGs already are in the United States waiting to get into residencies.

Meanwhile, the number of residency slots open to IMGs is about to shrink.

In 2005, the Assn. of American Medical Colleges recommended that its members increase enrollment and called for an expansion in residency slots. Schools are responding; graduate medical education funding is unchanged.

"If U.S. schools do increase enrollment by 30%, which is the goal, then we're closing the border to IMGs," said Subramaniam Balasubramaniam, MD, a California emergency physician and president of the American Assn. of Physicians of Indian Origin. "It's very difficult to increase residency slots."

While some companies explore the commercial side of externships, those shepherding volunteer efforts say they are overwhelmed.

The Oklahoma State Medical Assn. has an externship program supported by physician volunteers that graduated more than 200 IMGs last year. Medical society support staff said they field 15 application requests a week, and it can be months before applicants hear back.

Dr. Balasubramaniam said his organization helps 300 IMGs a year find either externships or research positions, another avenue to gain residency reference letters.

The Assn. of Physicians of Pakistani Descent of North America also helps link IMGs with opportunities, and the Mount Sinai Hospital in Miami offers a four-week program at no charge.

Dr. Tampus is confident that his externships made the difference in his second match attempt. He didn't get any offers the year before when he interviewed in internal medicine. This time he took a risk and focused on general surgery, his first love.

"I thought it would be impossible to get," Dr. Tampus said. "I got lucky."

He landed a general surgery residency in Brooklyn that begins in July. Until then, he'll be working two jobs to pay off the externship costs.

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Road to the Match

International medical graduates, like their U.S. counterparts, must pass the first two U.S. Medical Licensing Exams and the clinical skills exam before they can participate in the National Resident Matching Program. The number of IMGs who take the clinical skills test is higher than the number in the Match in part because IMGs may take the skills exam more than once.

Number of IMGs
Registered for
clinical skills exam
In the Match
2001 7,938 7,115
2002 9,892 6,585
2003 11,845 7,016
2004 11,636 7,686
2005 16,443 7,645
2006 18,109 8,877

Sources: Educational Commission of Foreign Medical Graduates, NRMP

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IMGs in the work force

A significant number of the physicians practicing in the U.S. are international medical graduates. Here is how their numbers shaped up in the most recent data from 2005.

  • 23.3% of licensed physicians in the U.S.
  • 27% of medical residents
  • 30.8%of internists
  • 29.9% of anesthesiologists
  • 29.8% of psychiatrists
  • 28.6% of pediatricians

States with the highest concentration of IMGs:

  • New Jersey: 39.6%
  • New York: 38.6%
  • Florida: 33.6%
  • Illinois: 32.3%

Source: American Medical Association

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IMGs as residents

One in every four medical residents in the U.S. is an international medical graduate. In 2005, the latest data available, this is how the number of IMG residents broke down:

Permanent resident 6,744 24.4%
Native U.S. citizen 4,296 15.5%
J exchange visitor visa 3,844 13.9%
H temporary worker visa 3,768 13.6%
Naturalized U.S. citizen 2,789 10.1%
F student visa 104 0.4%
Refugee/displaced person 123 0.4%
B temporary visitor visa 87 0.3%
Other 536 1.9%
Unknown 5,345 19.3%
Total 27,636 100.0%

Source: Journal of the American Medical Association, Sept. 6, 2006

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