A public health leader recently cited a 2017 BMJ study comparing quality of care between US and foreign-trained doctors. The flaws in the study offer numerous lessons
Another potential cofounder may be selection bias. It's possible that only the best (or most ambitious) international medical school graduates come to the US to practice. Was there adjustment for American citizens who couldn't get into a US medical school and hence went abroad before returning vs. non-US citizens who went to their own medical school? Or Caribbean medical schools vs UK medical schools for example. Too many cofounding factors I agree.
As a retired family physician with over 40 years of clinical experience, I find that studies such as this that try to reach generalized conclusions regarding widely divergent populations to be inherently flawed and unworthy of serious professional consideration. I have known individual physicians in both the US-trained as well as in the foreign-trained groups that I said to myself, "that Dr is going to have some problems." Each physician who obtains a license to practice medicine within any jurisdiction is like an actor on a stage, seen by the public eye and scrutinized by the state boards and hospital boards/committees as well as employers regarding their performance and competency. Each individual should be seen and treated fairly on an individual basis, not categorized as US vs foreign. Each barrel has a few bad apples, but I have been blessed to know and to work with some OUTSTANDING foreign-trained Dr's, though I myself am US-trained. Just wanted to weigh in with this opinion.
Unfortunately IMGs trained from poorly structured Medical schools give extremely inferior patient care in every aspect and that’s unfair to US medical graduates. I am not talking about Canada because Canadian health care system is highly screwed up system and Canada has poor quality of training compared to US plus Canada is highly Stingy in opening new medical schools and new residency programs and funny thing is they are hiring highly poorly skilled foreign medical graduates to treat their patient population… this is hypocrisy, height of hypocrisy in Canadian system where social medicine rules and social medicine does not favor Patients, it favors the system to save the money at the cost of patients life, no remorse for the people life in Canada.
"Unfortunately IMGs trained from poorly structured Medical schools give extremely inferior patient care in every aspect and that’s unfair to US medical graduates."
Do you have any legitimate source(s) to prove this or is it just your opinion? If the latter is the case, then I have to remind you that personal opinions hardly if ever matter in medicine.
Disagree with respect. It is not my personal opinion. It is well known fact because US medical Schools are far superior than any medical school in the world. The US medical training is simply excellent! Canadian system is SOCIAL medicine and even a child knows what social medicine is. Thank you
Dr. Ashish Jha, Foreign H-1B physicians are better than American physicians
Arrogance!!! and Ignorance!!!
The above study excluded how poorly the foreign physicians did during the covid pandemic, especially in African American and minority community hospitals.
In the state of Michigan currently for example; Sinai Grace, Harper Hospitals and Oakland University William Beaumont School of Medicine Ascension Providence Rochester Michigan are predominantly Arab/Indian ran hospitals in the heart of the city of Detroit and metro-Detroit were there are No European American White or Jewish American Physicians in their internal medicine or fellowship programs. Some from India and Arab countries are identifying as white which mildly confounds the absence of European and Jewish Americans. These institutions represent a clean cohort to study, where they included in the authors study population?
The morbidity and mortality rate is high in Arab/Indian ran internal medicine/hospital based programs and the cultural misuse of palliative care and hospice to hide the deaths of difficult to treat cases have been alleged by the minority community. In Detroit some community leaders have asked for them to be “shut down”.
India, Arab and middle eastern medical schools, internships, residency, fellowship and hospitals DO NOT ALLOW European White Americans or Jewish Americans to study, train, teach or work in their medical schools or hospitals. What measurement tools were used to compare outcomes and what real world variables were peer reviewed in-terms overseas versus state side outcome findings.
Patients and communities are the quality indicators of hospitals and a medical practice especially with the skewing of data with early consults or placement in hospice or palliative care before before full medical therapy has been exhausted.
Bold statements implying Americans are inferior at the same time their countries of origin are not recognized on the same level of the United States health care system and the contradiction if they are so great, why did they leave their countries and what happened to the care of their countrymen back in their respective countries?
Let’s compare apples to apples and not oranges. With all due respect.
I am an attending physician at a Detroit Medical Center (DMC) affiliated institution with residents and fellows. Your statement that "In the state of Michigan currently for example; Sinai Grace , Harper Hospitals and Oakland University William Beaumont School of Medicine Ascension Providence Rochester Michigan are predominantly Arab/Indian ran hospitals in the heart of the city of Detroit and metro-Detroit were there are No European American White or Jewish American Physicians in their internal medicine or fellowship programs" is untrue. Harper Hospital and Mt Sinai are DMC affiliated hospitals and DMC is owned by Tenet Healthcare Corporation. Please document your assertions with specific details.
This critique, while correctly identifying the problem of analytic flexibility, overemphasizes this single issue, neglecting other inherent limitations of observational research. It fails to adequately address the impossibility of controlling for all confounding variables, neglecting to provide specific examples relevant to the study. Its interpretation of the discrepancy between mortality and readmission findings is too simplistic, treating it as definitive proof of a flawed study rather than a point for further investigation. Furthermore, it underemphasizes the importance of the small effect size, failing to discuss its limited clinical significance, and focuses excessively on the impact of individual clinicians rather than considering potential systemic differences between medical training programs. This is too narrowly focused and misses key nuances that would provide a more balanced and comprehensive assessment of the BMJ study's limitations. The implications are obvious from the "conservative" in medicine bio
YOU Hit the nail on the head David! Besides the cost of education, the foundations of medicine need to change. The entire profession needs to change. The constant threat of litigation, stressful lifestyle, and corporate practice(ie big medical groups and hospitals) of medicine have created an atmosphere that is not palatable for most American born college students. Especially since there are many avenues for making a comparable living that don't include that baggage. Our home grown best and brightest have many better options.
What about medical fraud? Has anyone performed a comparison between foreign trained and US trained physicians comparing the rates of medical fraud between these two groups? Seems to me that I see a lot more shady practices among FMGs than USMDs.
There are huge variables in the treatment and facilities between hospitals where foreign grads practice and where USA trained specialists practice. Sicker patients tend to be treated at the medical centers that attach and pay USA doctors. Less ill patients often go to community and smaller hospitals where the preponderance of foreign grads practice. Sicker patients = higher death rate.
I'm a foreign born, foreign medical school graduate. I've been practicing in the USA for over 30 years. This is just my opinion. We have to keep in mind that the doctors who leave their home country, succeed in passing exams like USMLE, FMGEMS etc, are cream of the cream of their country. It is unfair to compare this group with US graduates at large. In my country of origin, I know of doctors whom I won't let treat my enemy. Perhaps, it would've been fairer to say that immigrant doctors are at least as competent as US graduates.
Disagree. Being IMG( international medical graduate) myself and practicing in USA for more than 30 years, sorry FMGS( IMGs) are highly unskilled, poorly trained with very poor knowledge, no concept of interactions , complete lack of medical ethics are so incompetent that I myself do not go to them if I am sick.
I am Not projecting anything, I am foreign medical graduate myself. Practicing 30 years in USA. I am giving you evidence based facts. USA is not perfect country to live in and it does have many flaws in its system but when it comes to healthcare, it is the Top most in the world. It is impeccable compared to all other countries.
I have experienced in UK, Canada, Australia, Switzerland, India and UAE and Ireland but there is No comparison to us healthcare. I am not getting any incentive then why should I do projection.
The timing of the release of this study coincides with a political push to open the flood gate for more doctors from outside the US to drown the medical profession.
Which will make the doctors and the medical associations drop their objections against a single payer Canadian/ British style healthcare system.
The study conclusion and even quoting it, is embarrassing.
American doctors are questionable when it comes to superior performance - doesnt matter whether you are FMG or IMG. Both species are consumerist capitalist imperialists whose foundation is weak at best. They have bad outcomes for their patients (american healthcare system is costlier with worse outcomes when compared with others in the world - a well known fact) and are a major contributor to global warming and climate change (thanks to their wasteful practices). What a waste of time discussing this paper !
Sorry, IMGs( international medical graduates) are with very poor training and are coming from highly unstructured health care system.
American health care system is highly structured with the most superior quality of training in the world.
I have seen many countries and their poor health care systems.
Those countries are creating butchers with remorseless healthcare system while USA has the best healthcare system with remorse and patient safety first.
Sorry you have typical poor country delusional mindset.
Sorry instead of using the word Muslim, you should just state the facts about International medical graduates in general are very poorly trained in medical skills, interactions, knowledge and understanding of the culture and ethics.
This is seriously impacting our health care system that we see thousands of IMGs with very poor training flocking over USA and giving our patients height of dissatisfaction.
With no empty and sympathy, no skills, no training.
But I don't know about "in general". When this happened I'd lost my regular family doc (Canada) and was in a 11 year wait for a new family doc. This ridiculous import doc had also been judged guilty of driving into a pedestrian but was given no sentence because we are in such dire need of docs, because in Canada we're simply NOT training enough docs.
I've also had very icky doc experiences with trad Christians. Like the time I asked my trad Christian dentist a question about root canals and teeth, and she answered "God just made them that way"
Religion has no business in science. Or at least that was my traditional position. But Covid thought me that my atheist compatriots are just as stupid.
A major flaw in the reasoning is not accounting for the survivor factor. That is, those who studied abroad and have made it to practice here have had a steep mountain to climb and those who succeed had to be hard working, motivated, resilient and smart. I practiced for 43 years, taught at 4 medical schools and had colleagues, students, residents and fellows from all over. It is all up to the individual. Each path had its own challenges but the final quality of the physician is really up to the individual. The rest is icing.
Patients are not care by one doctor 24h/ day; the admitting doctor can be foreign graduate but an American graduate can also care for the patient, 12 h/ day. You have several specialists consulting, team care (PAs, NPs, nurses, respiratory therapists, …), so there’s more than the name of the admitting physician.
A good portion of IMGs are American citizens who attended medical schools out side of US. The fair conclusion from this study should be: the care provided by IMG is no inferior than US graduates.
Another potential cofounder may be selection bias. It's possible that only the best (or most ambitious) international medical school graduates come to the US to practice. Was there adjustment for American citizens who couldn't get into a US medical school and hence went abroad before returning vs. non-US citizens who went to their own medical school? Or Caribbean medical schools vs UK medical schools for example. Too many cofounding factors I agree.
As a retired family physician with over 40 years of clinical experience, I find that studies such as this that try to reach generalized conclusions regarding widely divergent populations to be inherently flawed and unworthy of serious professional consideration. I have known individual physicians in both the US-trained as well as in the foreign-trained groups that I said to myself, "that Dr is going to have some problems." Each physician who obtains a license to practice medicine within any jurisdiction is like an actor on a stage, seen by the public eye and scrutinized by the state boards and hospital boards/committees as well as employers regarding their performance and competency. Each individual should be seen and treated fairly on an individual basis, not categorized as US vs foreign. Each barrel has a few bad apples, but I have been blessed to know and to work with some OUTSTANDING foreign-trained Dr's, though I myself am US-trained. Just wanted to weigh in with this opinion.
Unfortunately IMGs trained from poorly structured Medical schools give extremely inferior patient care in every aspect and that’s unfair to US medical graduates. I am not talking about Canada because Canadian health care system is highly screwed up system and Canada has poor quality of training compared to US plus Canada is highly Stingy in opening new medical schools and new residency programs and funny thing is they are hiring highly poorly skilled foreign medical graduates to treat their patient population… this is hypocrisy, height of hypocrisy in Canadian system where social medicine rules and social medicine does not favor Patients, it favors the system to save the money at the cost of patients life, no remorse for the people life in Canada.
"Unfortunately IMGs trained from poorly structured Medical schools give extremely inferior patient care in every aspect and that’s unfair to US medical graduates."
Do you have any legitimate source(s) to prove this or is it just your opinion? If the latter is the case, then I have to remind you that personal opinions hardly if ever matter in medicine.
Disagree with respect. It is not my personal opinion. It is well known fact because US medical Schools are far superior than any medical school in the world. The US medical training is simply excellent! Canadian system is SOCIAL medicine and even a child knows what social medicine is. Thank you
Dr. Ashish Jha, Foreign H-1B physicians are better than American physicians
Arrogance!!! and Ignorance!!!
The above study excluded how poorly the foreign physicians did during the covid pandemic, especially in African American and minority community hospitals.
In the state of Michigan currently for example; Sinai Grace, Harper Hospitals and Oakland University William Beaumont School of Medicine Ascension Providence Rochester Michigan are predominantly Arab/Indian ran hospitals in the heart of the city of Detroit and metro-Detroit were there are No European American White or Jewish American Physicians in their internal medicine or fellowship programs. Some from India and Arab countries are identifying as white which mildly confounds the absence of European and Jewish Americans. These institutions represent a clean cohort to study, where they included in the authors study population?
The morbidity and mortality rate is high in Arab/Indian ran internal medicine/hospital based programs and the cultural misuse of palliative care and hospice to hide the deaths of difficult to treat cases have been alleged by the minority community. In Detroit some community leaders have asked for them to be “shut down”.
India, Arab and middle eastern medical schools, internships, residency, fellowship and hospitals DO NOT ALLOW European White Americans or Jewish Americans to study, train, teach or work in their medical schools or hospitals. What measurement tools were used to compare outcomes and what real world variables were peer reviewed in-terms overseas versus state side outcome findings.
Patients and communities are the quality indicators of hospitals and a medical practice especially with the skewing of data with early consults or placement in hospice or palliative care before before full medical therapy has been exhausted.
Bold statements implying Americans are inferior at the same time their countries of origin are not recognized on the same level of the United States health care system and the contradiction if they are so great, why did they leave their countries and what happened to the care of their countrymen back in their respective countries?
Let’s compare apples to apples and not oranges. With all due respect.
American Jewish Medical Association does monitoring
Dear Reverand Doctor:
I am an attending physician at a Detroit Medical Center (DMC) affiliated institution with residents and fellows. Your statement that "In the state of Michigan currently for example; Sinai Grace , Harper Hospitals and Oakland University William Beaumont School of Medicine Ascension Providence Rochester Michigan are predominantly Arab/Indian ran hospitals in the heart of the city of Detroit and metro-Detroit were there are No European American White or Jewish American Physicians in their internal medicine or fellowship programs" is untrue. Harper Hospital and Mt Sinai are DMC affiliated hospitals and DMC is owned by Tenet Healthcare Corporation. Please document your assertions with specific details.
Please state make up and leadership running the programs and do you have Jewish Americans in their program?
You still did not denied what AAMC has reported or The Green Book and the organization Do No Harm.
This critique, while correctly identifying the problem of analytic flexibility, overemphasizes this single issue, neglecting other inherent limitations of observational research. It fails to adequately address the impossibility of controlling for all confounding variables, neglecting to provide specific examples relevant to the study. Its interpretation of the discrepancy between mortality and readmission findings is too simplistic, treating it as definitive proof of a flawed study rather than a point for further investigation. Furthermore, it underemphasizes the importance of the small effect size, failing to discuss its limited clinical significance, and focuses excessively on the impact of individual clinicians rather than considering potential systemic differences between medical training programs. This is too narrowly focused and misses key nuances that would provide a more balanced and comprehensive assessment of the BMJ study's limitations. The implications are obvious from the "conservative" in medicine bio
YOU Hit the nail on the head David! Besides the cost of education, the foundations of medicine need to change. The entire profession needs to change. The constant threat of litigation, stressful lifestyle, and corporate practice(ie big medical groups and hospitals) of medicine have created an atmosphere that is not palatable for most American born college students. Especially since there are many avenues for making a comparable living that don't include that baggage. Our home grown best and brightest have many better options.
What about medical fraud? Has anyone performed a comparison between foreign trained and US trained physicians comparing the rates of medical fraud between these two groups? Seems to me that I see a lot more shady practices among FMGs than USMDs.
There are huge variables in the treatment and facilities between hospitals where foreign grads practice and where USA trained specialists practice. Sicker patients tend to be treated at the medical centers that attach and pay USA doctors. Less ill patients often go to community and smaller hospitals where the preponderance of foreign grads practice. Sicker patients = higher death rate.
I think this is a classic example of a Primary Investigators having a desired result and then finding data to "cosign" their beliefs
I'm a foreign born, foreign medical school graduate. I've been practicing in the USA for over 30 years. This is just my opinion. We have to keep in mind that the doctors who leave their home country, succeed in passing exams like USMLE, FMGEMS etc, are cream of the cream of their country. It is unfair to compare this group with US graduates at large. In my country of origin, I know of doctors whom I won't let treat my enemy. Perhaps, it would've been fairer to say that immigrant doctors are at least as competent as US graduates.
Disagree. Being IMG( international medical graduate) myself and practicing in USA for more than 30 years, sorry FMGS( IMGs) are highly unskilled, poorly trained with very poor knowledge, no concept of interactions , complete lack of medical ethics are so incompetent that I myself do not go to them if I am sick.
LOL ... I smell projection in your comment.
I am Not projecting anything, I am foreign medical graduate myself. Practicing 30 years in USA. I am giving you evidence based facts. USA is not perfect country to live in and it does have many flaws in its system but when it comes to healthcare, it is the Top most in the world. It is impeccable compared to all other countries.
I have experienced in UK, Canada, Australia, Switzerland, India and UAE and Ireland but there is No comparison to us healthcare. I am not getting any incentive then why should I do projection.
The timing of the release of this study coincides with a political push to open the flood gate for more doctors from outside the US to drown the medical profession.
Which will make the doctors and the medical associations drop their objections against a single payer Canadian/ British style healthcare system.
The study conclusion and even quoting it, is embarrassing.
Dr Jah should have known better!
American doctors are questionable when it comes to superior performance - doesnt matter whether you are FMG or IMG. Both species are consumerist capitalist imperialists whose foundation is weak at best. They have bad outcomes for their patients (american healthcare system is costlier with worse outcomes when compared with others in the world - a well known fact) and are a major contributor to global warming and climate change (thanks to their wasteful practices). What a waste of time discussing this paper !
Sorry, IMGs( international medical graduates) are with very poor training and are coming from highly unstructured health care system.
American health care system is highly structured with the most superior quality of training in the world.
I have seen many countries and their poor health care systems.
Those countries are creating butchers with remorseless healthcare system while USA has the best healthcare system with remorse and patient safety first.
Sorry you have typical poor country delusional mindset.
I went to an emergency Muslim doctor once for back pain. She said I should consider my pain as a test from god.
Sorry instead of using the word Muslim, you should just state the facts about International medical graduates in general are very poorly trained in medical skills, interactions, knowledge and understanding of the culture and ethics.
This is seriously impacting our health care system that we see thousands of IMGs with very poor training flocking over USA and giving our patients height of dissatisfaction.
With no empty and sympathy, no skills, no training.
But I don't know about "in general". When this happened I'd lost my regular family doc (Canada) and was in a 11 year wait for a new family doc. This ridiculous import doc had also been judged guilty of driving into a pedestrian but was given no sentence because we are in such dire need of docs, because in Canada we're simply NOT training enough docs.
I've also had very icky doc experiences with trad Christians. Like the time I asked my trad Christian dentist a question about root canals and teeth, and she answered "God just made them that way"
Religion has no business in science. Or at least that was my traditional position. But Covid thought me that my atheist compatriots are just as stupid.
Uncalled for jab, you are on the wrong forum.
A major flaw in the reasoning is not accounting for the survivor factor. That is, those who studied abroad and have made it to practice here have had a steep mountain to climb and those who succeed had to be hard working, motivated, resilient and smart. I practiced for 43 years, taught at 4 medical schools and had colleagues, students, residents and fellows from all over. It is all up to the individual. Each path had its own challenges but the final quality of the physician is really up to the individual. The rest is icing.
Patients are not care by one doctor 24h/ day; the admitting doctor can be foreign graduate but an American graduate can also care for the patient, 12 h/ day. You have several specialists consulting, team care (PAs, NPs, nurses, respiratory therapists, …), so there’s more than the name of the admitting physician.
A good portion of IMGs are American citizens who attended medical schools out side of US. The fair conclusion from this study should be: the care provided by IMG is no inferior than US graduates.