A recent research study explored how citizenship status influences the specialty choices and practice locations of both U.S. citizen and non-citizen international medical graduates (IMGs), who represent about 25% of the active physician workforce in the United States. The results indicated that citizenship status significantly affects IMGs when deciding on their medical specialties and where they choose to practice. Historically, non-citizen IMGs were more likely to pursue primary care roles and serve in rural or underserved regions—however, this trend has seen a downward shift over the past ten years. Therefore, initiatives aimed at attracting physicians to primary care, particularly in areas of shortage, must consider the distinctive characteristics of IMGs.
Developing effective strategies to address the increasing need for primary care services, especially in areas lacking sufficient medical attention, is an ongoing challenge for policymakers. Recent research by the Harvard Pilgrim Health Care Institute proposes that policy measures aimed at recruiting physicians for primary care specialization, particularly in underrepresented regions, should be specifically designed according to the citizenship status of international medical graduates (IMGs).
The study’s findings were published on October 15 in the Journal of General Internal Medicine.
IMGs, which refer to graduates from medical schools situated outside the U.S. and Canada, currently constitute a quarter of all licensed doctors in the U.S. This group has been found to have a higher tendency to specialize in primary care, particularly in areas that are underserved nationwide. Nevertheless, their citizenship status—which influences their ability to live and work in the U.S. post-medical school—affects their specialty choices and practice locations.
“IMGs play a vital role in the U.S. health care system by often working in high-need and underserved regions,” noted Tarun Ramesh, the study’s lead author and a research fellow at the Harvard Pilgrim Health Care Institute. “Given that various factors might hinder their continued contributions, understanding how citizenship status impacts their specialty and practice location choices is essential for helping policymakers design better interventions that can motivate more IMGs to enter primary care, especially in rural and shortage-affected areas.”
The research involved an examination of 15,133 new doctors who accepted job offers between 2010 and 2019, utilizing data from the New York Resident and Fellows Exit Survey. The study included 8,177 U.S. medical graduates; 2,753 U.S. citizen IMGs; 1,057 permanent resident IMGs; and 3,146 non-citizen, non-permanent resident IMGs. It evaluated three specific outcomes: whether these new physicians selected primary care, whether a new primary care physician decided to work in a rural area, and whether a new primary care physician opted to practice in a health professional shortage area.
The researchers discovered that citizenship status significantly influences the specialty and practice location choices of IMGs, confirming that their contributions to the U.S. healthcare system vary based on their citizenship status. They found that, when compared to U.S. medical graduates, U.S. citizen IMGs were five times more likely, permanent resident IMGs were seven times more likely, and non-citizen non-permanent resident IMGs were nine times more likely to choose primary care. The analysis also highlighted two key trends: a reduction in the number of non-citizen, non-permanent resident IMGs entering primary care and an increased propensity for these IMGs to work in rural areas and health shortage regions.
“The significant role of IMGs in enhancing healthcare services in underserved communities is crucial,” asserted senior author Hao Yu, who is an associate professor of population medicine at Harvard Medical School and part of the Harvard Pilgrim Health Care Institute. He added, “While programs incentivizing visa availability may encourage non-citizen, non-permanent resident IMGs to practice in these essential areas, our findings indicate that more sophisticated efforts are necessary to make primary care a more appealing specialty.”
The authors recommend further investigation into factors like subspecialty choices, compensation, job satisfaction, and incentives for U.S. citizen, permanent resident, and non-citizen non-permanent resident IMGs, as well as evaluating recent state laws that offer provisional licensing pathways for IMGs to practice medicine.
