How do IMGs usually perform in residency compared to AMGs?

[NeedToStudy]

We often talk about what it takes for an IMG to get a residency in America, but I think another important question is how do IMGs usually perform once they get the residency. Yes I know we can't generalize and it's all about the individual but still, just talking generally, do IMG's ususally have trouble in residency? Do they have more trouble with the work than AMGs? Does it matter if the IMG is a US citizen or not?

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[colbgw02]

We often talk about what it takes for an IMG to get a residency in America, but I think another important question is how do IMGs usually perform once they get the residency. Yes I know we can't generalize and it's all about the individual but still, just talking generally, do IMG's ususally have trouble in residency? Do they have more trouble with the work than AMGs? Does it matter if the IMG is a US citizen or not?

 

[Law2Doc]

We often talk about what it takes for an IMG to get a residency in America, but I think another important question is how do IMGs usually perform once they get the residency. Yes I know we can't generalize and it's all about the individual but still, just talking generally, do IMG's ususally have trouble in residency? Do they have more trouble with the work than AMGs? Does it matter if the IMG is a US citizen or not?

The question is pretty naive because not all IMGs can be lumped together. If there are issues they will stem from (1) lack of knowledge of US hospital culture -- US patients, nurses, etc have certain expectations regarding doctors, and the US health system generally tends to have more of a rigid hierarchy than some parts of the world, and (2) language issues. Many IMGs come from system not all that different though so the question is strained.


There is a learning curve and having US rotations in US med schools often will let some start higher on the learning curve. But I think you are kind of missing the point of distinguishing why it's harder to get a US residency. The LCME ensures that US education is standardized. Without it, it's anyone's guess what an applicant knows, has been exposed to or achieved. it's like buying a Product with a Label you don't recognize. it might be good or not -- but why guess when there's plenty of products you know are good sitting on the next shelf.

 

[Trogghunter]

And then group 3: fmg residents who were attendings in their country. I know someone who was an icu attending overseas and went through IM residency here and an ENT attending that did IM. I wouldn't expect people like that to perform poorly.

 

[Raryn]

Why does it matter?

Lets say we told you IMGs perform worse in general. How would that change your behavior? Presumably, you'd work hard either way.

Or maybe you want us to tell you that IMGs perform better in general. Do you think that would give you license to slack off?

 

[Law2Doc]

And then group 3: fmg residents who were attendings in their country. I know someone who was an icu attending overseas and went through IM residency here and an ENT attending that did IM. I wouldn't expect people like that to perform poorly.

They still can have issues with culture and language. Medicine in the US is frequently less about knowing medicine and more about customer service and working the system. There are doctors out there who don't know as much medicine as they should, that have patients who rave about them. The guy with the best knowledge base can easily get the worst evaluations in residency because nobody complains that X had to look something up now and then, but they will if Y was brusque with them on the phone or had a poor bedside manner.

 

[TexasPhysician]

I've seen a few FMG's fired or had their contracts not renewed due to behavior or entitlement issues. They were respected physicians in their country, but here you redo training. They were harsh to nurses and staff and students. They felt being a resident was below them or at least acted like it openly.

Another FMG I know was a neurosurgeon in his home country who was doing a US FM residency. He was an excellent teaching resident and one of the best overall residents.

I have yet to see an AMG fired or non-renewed.

My total numbers are not enough to base a study on, so my experience may be nothing better than anecdotal.

 

[ThoracicGuy]

I've seen a few FMG's fired or had their contracts not renewed due to behavior or entitlement issues. They were respected physicians in their country, but here you redo training. They were harsh to nurses and staff and students. They felt being a resident was below them or at least acted like it openly.

Another FMG I know was a neurosurgeon in his home country who was doing a US FM residency. He was an excellent teaching resident and one of the best overall residents.

I have yet to see an AMG fired or non-renewed.

My total numbers are not enough to base a study on, so my experience may be nothing better than anecdotal.

I've seen AMGs nonrenewed before... I'm sure IMG/FMG firings/nonrenewals are probably a bit higher rate than AMGs, but AMGs aren't immune.

 

[TexasPhysician]

I've seen AMGs nonrenewed before... I'm sure IMG/FMG firings/nonrenewals are probably a bit higher rate than AMGs, but AMGs aren't immune.

Definitely not immune. I just have yet to witness it myself. There are threads on SDN about it though.

 

[Law2Doc]

I've seen AMGs nonrenewed before... I'm sure IMG/FMG firings/nonrenewals are probably a bit higher rate than AMGs, but AMGs aren't immune.

Ditto - seen it as well, more than once.

 

[Over9000]

The issue is, and we see it a lot in pathology, that FMGs underwent training that is unverifiable, and often times out of date or inadequate.

Furthermore, many lack the aptitude to learn at an appropriate rate, or are too proud to admit they are behind in their expected level here.

Some countries are particularly corrupt and medical degrees can be bought. Russia, India, Iraq and Iran come to mind. I've seen residents who I doubt have been to medical school at all given their lack of basic medical knowledge (basic medical terms, simple clinical differential diagnoses, simple management etc.)

We should have a hard line policy on accepting FMGs into residency.

 

[NeedToStudy]

The issue is, and we see it a lot in pathology, that FMGs underwent training that is unverifiable, and often times out of date or inadequate.

Furthermore, many lack the aptitude to learn at an appropriate rate, or are too proud to admit they are behind in their expected level here.

Some countries are particularly corrupt and medical degrees can be bought. Russia, India, Iraq and Iran come to mind. I've seen residents who I doubt have been to medical school at all given their lack of basic medical knowledge (basic medical terms, simple clinical differential diagnoses, simple management etc.)

We should have a hard line policy on accepting FMGs into residency.

How then did they pass the USMLE?

 

[thehundredthone]

Some countries are particularly corrupt and medical degrees can be bought. Russia, India, Iraq and Iran come to mind. I've seen residents who I doubt have been to medical school at all given their lack of basic medical knowledge (basic medical terms, simple clinical differential diagnoses, simple management etc.)

While I don't completely disagree (Russia, China and Central Europe advertise medical degrees that can be earned in 5-7 years, and there is almost no clinical training), the USMLEs supposedly set a minimum standard for basic medical knowledge, don't they? Otherwise one would have to question AMGs who clear the exams too.

The issue is, and we see it a lot in pathology, that FMGs underwent training that is unverifiable, and often times out of date or inadequate.

Isn't this something that can be screened for when the program is looking through applications? No one can circumvent the process of getting into residency, so it is equally the programs' responsibility to control the quality of their incoming residents.

We should have a hard line policy on accepting FMGs into residency.

You risk throwing the baby(ies?) out with the bath water. FMGs do play a definite role in the ecosystem of practice given the dearth of AMGs willing to practice primary care in undesirable locations.

 

[NotAProgDirector]

How then did they pass the USMLE?

I have heard concerns raised that taking usmle internationally can be done with fake id's without much scrutiny. I don't know the veracity of this.

 

[Jecave]

I have heard concerns raised that taking usmle internationally can be done with fake id's without much scrutiny. I don't know the veracity of this.

You give your finger prints when you appear for the exam.

 

[NotAProgDirector]

Thanks for the correction. Presumably you give your fingerprints when you register for the exam. So what stops someone from just registering for someone else? If they keep all fingerprints on file, that would presumably prevent someone from registering more than once.

 

[thehundredthone]

Thanks for the correction. Presumably you give your fingerprints when you register for the exam. So what stops someone from just registering for someone else? If they keep all fingerprints on file, that would presumably prevent someone from registering more than once.

You need to send in a certificate of identity with your signature (matching your ID, usually the passport) and photograph certified by your medical school in an envelope sealed by the medical school, when registering for the first time. Along with fingerprinting, Prometric also takes your photograph and records your ID (whatever you used while registering) when you appear for the test, as per the USMLE BECS program. Your ERAS ID is linked to the USMLE ID so that provides continuity. Your FSMB identification for Step 3 must be notarised by a public notary (they prefer the US embassy), and is also linked to your ECFMG/USMLE ID.

The only way to register for someone else then would be to have the medical school complicit in the matter, and also write the Step 2CS and Step 3 for the person. Even if you don't trust Prometric's international centres, there are still two exams to be taken inside the USA (plus you have to enter the country for each of them).

 

[NotAProgDirector]

I stand corrected!

 

[galactus]

I've seen my fair share of good and bad AMG/IMG residents. To the OP, you already answered your own question. It's all based on the individual.

 

[Nidor]

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[Law2Doc]

I'm quite surprised to see the doubts and preconceptions that exist about IMG's.
The USMLE's should confirm their knowledge and the interviews should establish if they fit in the culture of residency programs. After those selections is your chance of having a 'bad' resident really higher then with AMG's or do these exceptions just stand out more?

The USMLE was never designed to be more than a P/F test of minimum basic knowledge -- not really a test useful to tell anyone anything about depth of knowledge or aptitude. And an interview is a couple of hours tops, so it's not going to be the same judge of whether one fits into a culture as someone who lived in that culture for two years of med school and got good evaluations. How do you know how that person interacts with US patients, nurses? Being able to present yourself well in a short interview while wearing a suit and tie is often very different than how you handle long hours on the wards, interacting with others. The US grad comes with letters from attendings saying "I worked on the wards with this guy for X weeks, and he will be a Great resident" -- that trumps anything you will be able to discern in a few minutes on interview day. And when you throw potential language barriers in to boot, that can create even more issues. So yes, we don't have as good a way to evaluate foreign trained doctors and relying on just the interview and USMLE would OFTEN net you people that won't work out. The US educated guy has spent two years doing rotations in US wards, and comes with letters and people we can talk to, and has had fairly standardized experiences thanks to LCME. They won't have had the "lite" versions of rotations like some of the offshore schools contract for at community hospitals, and they won't be coming from places where maybe patients don't have the same expectations or where support staff isn't regarded as a distinct profession with it's own role in evaluating their doctor colleagues, or where people work 50 hours a week and call it a lot, or where saying "I don't know" is regarded as worse than making something up.

 

[Nidor]

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[Law2Doc]

If they succeed in convincing the PD despite those reasonable doubts, despite facing higher scrutiny then any US grad, despite having received educations not even remotely tailored to the USMLE's (not taking Caribbean grads into account here), would you not expect them to be exceptional candidates?

I'm not sure what you are asking. "convincing the PD" isn't a useful standard to evaluate excellence -- PDs get duped by someone every year. which is why so many focus on the US grads with the LCME seal of approval on his educational experience. You aren't excellent because you convince a PD you will be. The proof is always in the pudding.

 

[Nidor]

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[Law2Doc]

fair enough. I guess I assumed that those that succeed in matching found ways to compensate for their less standardized background. Either by excelling in standardized tests, getting US letters of recommendation, doing visiting rotations or a combination of the above. I was simply surprised that after all that they are still perceived as less capable/more likely to fluke out.

You have to do all that to just get considered. That doesn't make you an exceptional candidate. That's the baseline before they even decide if you are someone likely to have cultural issues.

 

[thehundredthone]

You have to do all that to just get considered. That doesn't make you an exceptional candidate. That's the baseline before they even decide if you are someone likely to have cultural issues.

It's really an administrative issue then, isn't it. The reality is that there is a hole and it's being filled by people willing to work, at the expense of their other deficiencies. There is also the question of certain programs not filling their spots and eventually losing their ACGME accrediation if they don't take IMGs.

An LCME seal isn't foolproof either, given that some AMGs also find residency too rough (however this is not an argument against the standard at all, it definitely needs to exist). At the end of the day, like the other thread about the NYU resident, there is still no real foolproof way to ensure that residents coming into a program can truly withstand the workload and deal with all the intangibles.

 

[Law2Doc]

It's really an administrative issue then, isn't it. The reality is that there is a hole and it's being filled by people willing to work, at the expense of their other deficiencies. There is also the question of certain programs not filling their spots and eventually losing their ACGME accrediation if they don't take IMGs.

An LCME seal isn't foolproof either, given that some AMGs also find residency too rough (however this is not an argument against the standard at all, it definitely needs to exist). At the end of the day, like the other thread about the NYU resident, there is still no real foolproof way to ensure that residents coming into a program can truly withstand the workload and deal with all the intangibles.

You never really know what you are getting, but having the LCME brand name at least gives you an idea of what their experiences would have consisted of. The guy coming from abroad could be great but he's not a known brand. PDs also like to go back to the same wells over and over -- you get a fantastic resident from school X, then school X is on your radar again next year. Makes it very hard for outsiders to break in, and every cultural snafu hurts future similar applicant trying to follow.

 

[thehundredthone]

You never really know what you are getting, but having the LCME brand name at least gives you an idea of what their experiences would have consisted of. The guy coming from abroad could be great but he's not a known brand. PDs also like to go back to the same wells over and over -- you get a fantastic resident from school X, then school X is on your radar again next year. Makes it very hard for outsiders to break in, and every cultural snafu hurts future similar applicant trying to follow.

No argument there at all. I was making a more general statement in my second paragraph.

 

[MDtoUSMLE]

AMGs perform better in laid back programs especially the University ones. IMGs perform better in the so called " malignant programs" where AMGs usually don't apply. I have witnessed AMGs kicked from there 1st year in such programs especially in Brooklyn. You can't really make a rule here. Each individual has his/her own capacity and life issues, never the less, mental issues which shape their behavior especially fresh graduates who have not been yet into the rudeness of health system.

 

[anes]

Hands down the worst physician in my residency class was an IMG. Hands down the best person in my class was also an IMG. Both came from some of those "shady" countries mentioned earlier. BTW...the worst person completed a full residency in their home country in the same specialty.

The person wasn't considered bad because they had been taught a different way in their home country. They seemed to lack both medical knowledge and procedural skill sets.

 

[colbgw02]

AMGs perform better in laid back programs especially the University ones. IMGs perform better in the so called " malignant programs" where AMGs usually don't apply. I have witnessed AMGs kicked from there 1st year in such programs especially in Brooklyn. You can't really make a rule here. Each individual has his/her own capacity and life issues, never the less, mental issues which shape their behavior especially fresh graduates who have not been yet into the rudeness of health system.

 

[Law2Doc]

AMGs perform better in laid back programs especially the University ones. IMGs perform better in the so called " malignant programs" where AMGs usually don't apply. I have witnessed AMGs kicked from there 1st year in such programs especially in Brooklyn. You can't really make a rule here. Each individual has his/her own capacity and life issues, never the less, mental issues which shape their behavior especially fresh graduates who have not been yet into the rudeness of health system.

Well, most of the time if a US grad goes to a malignant program popular with the IMGs, he wasn't exactly a superstar in med school, so you are comparing one groups worst to another's best. And a malignant program that historically has to fill with IMGs is going to shrug off a lot more of the cultural hurdles because those issues are the norm for them. Given that dichotomy I would certainly hope the IMG performed well. But that doesn't really mean IMGs in the abstract "perform better" in this situation because they weren't going against someone representative -- the game was rigged. They were playing against the second string. So you really can't extrapolate that conclusion to the average AMG/IMG or program. In a malignant program, the worst of the class often becomes the whipping boy. If a better AMG ended up going to that program in Brooklyn the tables would flip, and it would be equally unjustifiable to write that AMGs handle malignancy better than IMGs.

 

[quique2]

I'll offer my own two cents to the OP, as an IMG in a program with somewhere around 30% IMGs. Based on my own completely subjective observations, in general we tend to have a harder time starting out, with a steeper learning curve than the US grads, but have equal or better knowledge base and decision making capacity (not that those are the most important skills an intern needs). Many IMGs nationwide except maybe the Carib grads have done some form of clinical work and therefore have some true independent experience. I remember personally having trouble with different styles of rounding and presentations and not really knowing what was expected of me on a day-to-day basis. Some of my foreign grad friends also had similar issues. It evened out after a few months. In terms of how they perform during, the IMGs worked pretty hard to get in and generally keep it up during residency, barring a couple of exceptions... those who want to are able to pump out good research and their fellowship matches are pretty good (though being an IMG +/- needing a visa hurts the same as it does for residency). Same as anyone else really. Work hard and reap the rewards.

Where I am, language or culture are not usually an issue for the most part. Maybe that's because most of the IMGs are from the Western hemisphere to begin with so that probably plays a role.

 

[flexdent11]

FMGs have a very hard time getting into the system here. Imagine if tables were turned and AMGs were to practice in foreign countries, they would not do it because culture, language and all that aside, outside there most countries lack the technology that is used here.. Some of you write as if you own medicine.thumbs up FMGs. And leave alone medicine, this country is held by immigrants who work their butts off trying to make a living and survive here because hell yes, the economy is much better than where they came from. BITE ME!

 

[colbgw02]

Interesting tack.

 

[gutonc]

Not to mention helpful to the discussion.

 

[MU420]

FMGs have a very hard time getting into the system here. Imagine if tables were turned and AMGs were to practice in foreign countries, they would not do it because culture, language and all that aside, outside there most countries lack the technology that is used here.. Some of you write as if you own medicine.thumbs up FMGs. And leave alone medicine, this country is held by immigrants who work their butts off trying to make a living and survive here because hell yes, the economy is much better than where they came from. BITE ME!

Sorry, what's the point you're trying to make?

 

[NeedToStudy]

Sorry, what's the point you're trying to make?

I think he's trying to make the case that FMG's are awesome.

 

[gutonc]

I think he's trying to make the case that FMG's are awesome.

He's doing a pretty bad job of it then.

 

[DermViser]

FMGs have a very hard time getting into the system here. Imagine if tables were turned and AMGs were to practice in foreign countries, they would not do it because culture, language and all that aside, outside there most countries lack the technology that is used here.. Some of you write as if you own medicine.thumbs up FMGs. And leave alone medicine, this country is held by immigrants who work their butts off trying to make a living and survive here because hell yes, the economy is much better than where they came from. BITE ME!

AMGs, as a rule, don't usually want to practice in foreign countries, they want to practice in the same country they are born in or went to med school in -- the United States. FMGs come here instead of practicing in their own country, where their med schools prepared them to serve the needs of their country's citizens.

 

[DermViser]

I'm quite surprised to see the doubts and preconceptions that exist about IMG's.
The USMLE's should confirm their knowledge and the interviews should establish if they fit in the culture of residency programs. After those selections is your chance of having a 'bad' resident really higher then with AMG's or do these exceptions just stand out more?

Seriously?

 

[chalamilasidney]

Interesting thread...at the end of the day, it's the patients that matter! we need the best people out there, no matter where they were born.

 

[Redpancreas]

We often talk about what it takes for an IMG to get a residency in America, but I think another important question is how do IMGs usually perform once they get the residency. Yes I know we can't generalize and it's all about the individual but still, just talking generally, do IMG's ususally have trouble in residency? Do they have more trouble with the work than AMGs? Does it matter if the IMG is a US citizen or not?

Each IMG is different just like each AMG is different. Take one who graduated from a top university in the UK/Southeast Asia who's traveled the world and knows better than English than some Americans and compare them to a Caribbean grad and you're probably looking at the best and worst XMGs. You could say AMGs are a more consistent product given the uniform path they all take. That said, AMGs do have a small cultural advantage and (as long as they're not jerks) tend to be more liked by patients.

 

[Raryn]

Each IMG is different just like each AMG is different. Take one who graduated from a top university in the UK/Southeast Asia who's traveled the world and knows better than English than some Americans and compare them to a Caribbean grad and you're probably looking at the best and worst XMGs. You could say AMGs are a more consistent product given the uniform path they all take. That said, AMGs do have a small cultural advantage and (as long as they're not jerks) tend to be more liked by patients.

Caribbean grads, with the sole exception of Puerto Rico, aren't AMGs. And Puerto Rico usually isn't grouped in the with Caribbean grads (due to being LCME accredited, even if it's there geographically).

The "worst" AMGs are probably from some of those newer schools that are still working out the kinks. Grouping all the US med schools together, my bet is the weakest students would come from those newer DO schools that don't even have an associated hospital and require the students to arrange all of their own rotations (which wouldn't fly with LCME accreditation but somehow COCA allows it).

 

[chalamilasidney]

Are there MD/PhDs here? if so, my question is: can a person apply and receive multiple NIH grants (Ks/Rs) at the same time? do you anyone in residency or fellowship or postdoc who did this?
also, can MDs enter PSTP?

 

[gutonc]

Are there MD/PhDs here? if so, my question is: can a person apply and receive multiple NIH grants (Ks/Rs) at the same time? do you anyone in residency or fellowship or postdoc who did this?
also, can MDs enter PSTP?

You can't have a K and an R at the same time, but you can have multiple R's. There are also multiple different kinds of K and R grants, and they are extraordinarily difficult to get these days. I'm not sure if there are citizenship requirements attached to K and R grants, like there are to T training grants.

Yes, anyone can enter a PSTP, assuming they're interviewed/ranked/matched. The citizenship issue mentioned above may be a limiting factor.

 

[AdmiralChz]

Interesting thread...at the end of the day, it's the patients that matter! we need the best people out there, no matter where they were born.

Resurrecting after 4 years is an interesting choice.

And this is about patients. You want your housestaff to have solid familiarity with the American healthcare system, electronic medical records and have some baseline medical knowledge before they start. Some places do a very poor job at some or all of this, that’s just a fact.