The International Medical Graduate in US Academic General Surgery FREE

SINCE THE early 1960s international medical graduates (IMGs) have played a major role in the provision of health care in the United States. In 1963, IMGs formed a little more than 10% of the physician work force; by 1970, this number had risen to almost 18%.¹ Today, IMGs constitute about 24% of US physicians.¹

This study determines and delineates the contributions of graduates of medical schools outside of the United States who came to the United States for surgical training and then joined the academic surgical faculty.

A questionnaire was sent to the departments of general surgery of 128 medical schools and clinics that have independent surgical training programs (Figure 1). The questionnaire asked for (1) the names of those individuals who had graduated from foreign medical schools but had their surgical training in the United States, (2) the area of expertise of these individuals, and (3) the present positions of these individuals. No attempt was made to identify US citizens who went to foreign medical schools and then returned to the United States for surgical training. The survey was conducted between August 1992 and May 1994. However, responses to the survey were received as late as December 1995.

Of the 128 medical schools and clinics that received the questionnaire, 122 (95.3%) replied. Of the 122, 108 (88.5%) had at least 1 IMG on their faculty. Fourteen (11.5%) of those who replied did not have any IMGs on their faculty. Five hundred seventy-two IMGs were identified from the surgical faculty, of which 538 were men and 34 were women. These individuals represent 72 countries or colonies and most continents and regions of the world (Table 1). The countries with at least 10 or more graduates on academic surgical faculties in the United States were the following: India, 88; Canada, 62; South Africa, 28; the United Kingdom, 28; the People's Republic of China, 25; Lebanon, 22; Argentina, 19; Italy, 15; Egypt, 14; Japan, 14; Iran, 13; the Philippines, 13; Peru, 13; Germany, 13; Ireland, 12; South Korea, 11; Mexico, 11; and Israel, 11.

When grouped according to continents or regions of origin, the following number of IMGs on academic surgical faculties in the United States was noted: North America, 73; Central America, 6; South America, 57; West Indies, 15; Europe, 123; Africa, 50; Middle East, 62; Asia, 172; and Australia or New Zealand, 10. In 4 cases, the country of origin was not stated.

The distribution of the IMGs in the United States is as follows: 142 in the midwest; 133 in the mid-Atlantic states; 96 in the southern states; 84 in the Pacific Coast states; 53 in the New England states; 31 in the southwestern states; 22 in Hawaii; 6 in the Rocky Mountain states; and 5 in Washington, DC. The states with the most IMGs were California, 78; New York, 75; and Illinois, 42.

Table 2 shows the distribution of the various individuals in general surgery or its subspecialties. In some parts of the country, cardiovascular surgery, orthopedics, urology, otolaryngology, orthopedics and sports medicine, and anesthesia are under the department of surgery. This is not true for each and every program because this questionnaire was sent only to the departments of general surgery.

The academic ranks of the 572 individuals were as follows: professor, 182; associate professor, 142; assistant professor, 216; instructors, 19; and research associates, 13.

Fourteen of the 572 individuals are present or recent past chairpersons of their departments (Table 3). The number of IMGs appointed to academic surgical faculties in the United States per decade could also be determined from the questionnaire. There was 1 appointment in 1959; 35 appointments between 1960 and 1969; 114 appointments between 1970 and 1979; 221 appointments between 1980 and 1989; and 190 appointments between 1990 and 1995, which was when the survey ended. In 11 cases, no year was given. The number of appointments between 1990 and 1995 suggests that the number of IMGs being appointed to academic surgical faculties is increasing even though the number of IMGs in training programs in the United States is declining.

To understand the role of the United States in international medicine, one needs to look at the history of medical education in this country. In colonial days, the United States was dependent on other countries, chiefly England, for its educational and professional needs. For a century and a half, this country did not have a medical school until one was established in 1765 at the University of Pennsylvania, Philadelphia. The founding of this medical school was succeeded by schools at The King's College in Briarcliff Manor, NY, and Harvard in Boston, Mass.² These institutions were not the chief contributors of physicians during the late 18th and early 19th century, as by 1801 they had produced only 300 graduates. Immigration continued to provide educated professionals who provided medical care. During the time when there were no medical schools, an apprenticeship system of teaching had developed. However, this system trained young physicians without effective controls of their quality or competence. From 1776 to 1861, because of the break with England and after the Revolutionary War, US medicine came under French influence. The French system placed great emphasis on careful clinical observation rather than experimental investigation.² By the time of the Civil War, there were 65 medical schools in the United States. Medical education at this time was still mainly preceptorships with no formal education. This lack, combined with the abysmal results of surgical treatment of war wounds during the Civil War, resulted in the formation of the Association of American Medical Colleges in 1876. The task of the Association of American Medical Colleges was to improve medical education in the United States. From 1870 to 1914, US medicine came under German influence. In fact, 15000 Americans traveled to Germany, Switzerland, or Austria to study during this period. Well-known among these graduates was Alton Oschner, MD, who founded the Oschner Clinic in Louisiana; William Halsted, MD, considered the father of American surgery; and William H. Welch, MD, founder of The Johns Hopkins University, Baltimore, Md. The German system of research laboratories, full-time teachers and investigators, allegiance to the university, and use of experimental methods to study problems became the attraction for American students.² Most of the 15000 who traveled abroad returned to the United States.

Between 1914 and 1945, the United States was established as a leader of medical science and teaching. Both world wars had done much to destroy the medical systems of Europe. In 1948, the Association of American Medical Colleges created the committee on international relations in medical education. The responsibility of this committee was to maintain a registry of US faculty seeking experiences abroad, identifying departments in this country that wanted to receive foreign scholars for training, and facilitating international affiliations and the exchange of students and faculty.² At the end of World War II, training programs were expanded to accommodate returning veterans. In 1950, veterans finished their training but the positions they filled remained open. To fill these positions, laws were passed (Public Law No. 89-236 and No. 92-225) allowing IMGs to enter the United States to fill these training slots.³ Most came under the J visa (exchange visitor program). Between 1962 and 1975, 47000 IMGs were admitted to the United States.² Many members of the present academic surgical faculty came during that period.

It is clear that most IMGs are in practice in this country. According to the American College of Surgeons' records, there were 43199 active fellows in the college in 1993. Of these fellows, 6527 (15%) were surgeons with degrees from foreign schools. Of these 6527 surgeons, 572 (8.8%) were in academic surgery. The approximate number of faculty in US academic surgery is 5399, of which 572 (10.6%) are IMGs. Ten percent of the present residents in surgical training in this country are from foreign medical schools.¹ The surgical faculty from Loyola University of Chicago Stritch School of Medicine, Maywood, Ill, were asked to informally grade the 572 individuals as to whether they were internationally or nationally known. Of the 572, 8.8% were thought to be nationally and internationally known and 14.0% were thought to be nationally known. A review of the information available about the 572 graduates shows that they have made notable contributions in various fields of surgery, including anatomy, biliary surgery (including surgery of bile duct tumors), breast surgery, burn surgery, bariatric surgery, cardiovascular and thoracic surgery, critical care surgery, colorectal surgery, surgery for cirrhosis, endocrine surgery, endoscopic surgery, gastrointestinal tract motility surgery, hernia repair, hormone receptor surgery, hepatic surgery, head and neck surgery, hyperalimentation, laparoscopy, lithotripsy, surgery for melanomas, microsurgery, neurosurgery (including radiosurgery), orthopedics and sports medicine, pancreatic surgery, pediatric surgery, surgery for portal hypertension, surgery for reflux esophageal disease, surgery for retinal disease, surgical oncology, surgical research, surgical education, statistics, surgery for thrombosis, transplantation surgery and immunology, trauma surgery, urology and incontinence, and wound healing. The importance of these contributions is certainly underscored by the 95% response to this survey.

While it is true that only 14 (2.4%) of the 572 surgeons are chairpersons of departments, many of the 572 individuals are either division or section chiefs. The 14 department chairpersons are all well-known individuals in their fields. Herand Abcarian, MD, is well-known in colorectal surgery; Naji Abumrad, MD, in endocrine surgery; David Antonenko, MD, in general surgery and critical care; Murray Brennan, MD, in surgery for gastrointestinal tract malignant neoplasms, especially pancreatic carcinoma, soft tissue sarcomas, and endocrine neoplasms; Aldo Casteneda, MD, in pediatric cardiovascular surgery; Lawrence Cheung, MD, in gastrointestinal tract physiology; Haile Debas, MD, in pancreatic disease and surgery; J. Michael Henderson, MD, in portal hypertension and liver transplantation; Arnold Luterman, MD, in burn surgery; A. Rahim Moosa, MD, in gastrointestinal tract oncology, especially pancreatic carcinoma; Carlos Pellegrini, MD, in gastrointestinal tract motility and pancreatic disease; Ricardo Rossi, MD, in gastrointestinal tract oncology; John J. Ryan, MD, in gastrointestinal tract oncology and renal transplantation; and Alexander J. Walt, MD, in trauma and breast surgery. In addition, Dr Walt served as president of the American College of Surgeons.

The ranks of the individual physicians were then correlated with the year of their first appointment. It seemed that most of the individuals were at the appropriate rank for their years of service. This would suggest that they had achieved their promotions based on individual performance and experience and at proper intervals.

Even though the number of IMGs coming to the United States for surgical training has decreased, the number of appointments of IMGs to academic surgical faculties has increased. If the present trend continues, the decade from 1990 to 1999 will see the largest number of appointees to surgical faculties. It would be most interesting to see in a future survey whether this trend will continue. No specific observations can be made about the distribution of the IMGs in the United States. It is quite possible that the preponderance of IMGs in the midwest, mid-Atlantic, and southern states may be the result of individual choice and environment rather than any other factors. This demographic distribution may also be a source for future study.

In conclusion, IMGs account for 10% of the current academic surgical faculty in the United States. These graduates come from all countries and regions of the world. International medical graduates occupy faculty positions commensurate with their experience. Fourteen are or have been department chairpersons. Since 1960, there has been an increasing number of appointments of IMGs to surgical faculty of the departments of surgery. The results of this survey suggest that the experience of the IMGs in US academic surgery has been quite favorable.

Reprints: Gerard V. Aranha, MBBS, FRCSC, Section of Surgical Oncology, Loyola University of Chicago Stritch School of Medicine, EMS 110-3236, 2160 S First Ave, Maywood, IL 60153.