Why Do Foreign-Trained Physicians Have Lower Mortality Rates Than U.S.-Trained Docs?

An emerging area of research looks at how physician characteristics affect outcomes. International medical graduates are the latest group found to have better results than U.S.-trained medical doctors.

Medicare patients treated by international medical graduates (IMGs) are less likely to die than patients treated by non-IMGs, according to a study published by The BMJ this month.

More specifically, 30-day mortality rates were 11.2% among patients treated by IMGs and 11.6% among patients treated by physicians who trained in the United States, according to the analysis of Medicare data for more than 1.2 million hospitals covering more than 44,000 internists between 2011 and 2014.

Study co-author Yusuke Tsugawa, MD, MPH, PhD, a research associate at the department of health policy and management at the Harvard T.H. Chan School of Public Health, shared his insights into the findings. The transcript below was lightly edited.

HealthLeaders Media: You conducted this study years before President Trump's travel ban was ordered. What made you want to research outcomes of IMGs then?

Yusuke Tsugawa, MD: We knew that the U.S. heath system was relying on foreign-trained doctors in terms of quantity. One in four doctors in the United States is foreign-trained, and these doctors are more likely to deliver care in rural and underserved areas.

However, little has been studied about the quality of care delivered by foreign-trained doctors. We found that foreign-trained doctors are a valuable part of the workforce for the U.S. health system, both in terms of their quantity and quality.

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HLM: Is medical education and training for IMGs a possible reason for the lower mortality rates seen among their patients? Or is the differentiator something about the personal attributes of IMGs?

Tsugawa: Our study did not compare the quality of medical education in the United States and in other countries. What our findings suggest is that the United States is allowing the best and brightest to come and practice medicine by setting a high bar. And I think that is the reason why foreign medical graduates had slightly better outcomes.

HLM: A recent study comparing outcomes of female vs. male physicians described the difference as "modest but clinically important." How would you characterize the findings of your study?

Tsugawa: The difference in patient mortality for foreign vs. U.S. medical graduates was about the same size as the difference between male and female doctors. I think the difference was modest but clinically meaningful.

HLM: Your research also found that costs were slightly higher for patients treated by IMGs. To what do you attribute that variation and why is it important?

Tsugawa: Slightly higher costs for foreign medical graduates may be because they order more diagnostic tests or more often consult with specialists.

HLM: What do you want healthcare leaders to take away from your research? Are there action points to help U.S. trained physicians achieve better outcomes?

Tsugawa: I think healthcare leaders should not judge trainees based on where they got their medical education—especially for foreign-trained doctors—because it is hard to evaluate the quality of education of foreign medical schools.

Instead, they should assess doctors based on valid and reliable evidence that is readily available by analyzing the claims data or EHR for each physician in many institutions.

HLM: Do you have plans to follow up on this research?

Tsugawa: We are currently studying other characteristics of physicians that may be associated with better patient outcomes at lower costs.

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