By Carolina Torres Perez-Iglesias
International Medical Graduates (IMGs) currently make up 25% of all licensed physicians in the United States and a fifth of all first-year residency positions annually.1-3 In general surgery, IMGs commonly start training as non-designated preliminary residents (NDPR). Unfortunately, less than 50% of these residents will complete surgical training.4-6
What makes IMGs different?
A potential contributor to the low success rate in surgery could be that IMGs are often perceived as less desirable than US medical graduates (UMG) . A study that polled members of the Association of Program Directors of Surgery found that 87% preferred offering positions to USMG over IMGs despite having equal qualifications.7 More than half also reported purposefully avoiding IMGs, in part because of the perceived potential for language barriers, the concern for substandard quality and abilities compared to USMG, and the lack of familiarity with educational standards at non-US medical schools. A successful preliminary year in general surgery can help reassure programs against these unfounded concerns.
A survey conducted at my institutions, Beth Israel Deaconess Medical Center, identified that preliminary general surgery residents, most of whom are IMGs, face unique challenges and stressors in addition to those faced by categorical residents. Over 90% of faculty and residents in the program believe that NDPR experience added stressors that may adversely affect their clinical performance during the academic year. Respondents also believed NDPR are at a higher risk of being perceived negatively if they express dealing with stressors and 75% of NDPR admitted to fear of discussing stressors with faculty or senior residents for this reason [unpublished work].
How can we support IMGs in surgery?
Our survey also demonstrated that faculty and peer trainees are invested in the well-being and success of the NDPR and that they represent an important part of their support system. For this reason, our program designed a novel structured mentorship program for NDPR that launched in 2021. In the two years of implementation, 94% of our NDPR that were part of the program were offered a categorical surgical residency position. Faculty and categorical residents serve as mentors, and they have also benefited from this initiative by participating in workshops on effective mentoring and in community-building activities. Despite some mentors not having a background being a preliminary resident or an IMG, we have noticed incredible value in cross-mentorship. This also reduces the diversity tax put on this population. We hope that this initiative will foster an improved sense of belonging and support within our institution and improve outcomes for our surgical trainees. In addition to mentorship, the program includes ABSITE study support, community-building activities, and informative sessions on immigration, legal and financial topics.
How else can YOU help?
- In addition to specialized mentorship, IMGs need targeted interventions for professional and personal development, such as pre-residency workshops that teach essential competencies for IMGs to excel during residency. For this reason, we are conducting a survey aimed to identify the objective and subjective measures of performance that IMGs, faculty and residents in general surgery programs can use to evaluate NDPR.
If you are interested in providing your valuable input, you can find the survey in the following link: https://redcap.bidmc.harvard.edu/redcap/surveys/?s=9HJFW9J9CK4EHXLY
- American Medical Association. How IMGs have changed the face of American medicine. Accessed May 1, 2022, https://www.ama-assn.org/education/international-medical-education/how-imgs-have-changed-face-american-medicine
- Educational Commission for Foreign Medical Graduates. Match Day adds 7500 IMGs to US GME programs. Accessed May 12, 2022, https://www.ecfmg.org/news/2021/03/19/match-day-adds-7500-international-medical-graduates-to-u-s-gme-programs/
- National Resident Matching Program. Charting Outcomes in the Match: International Medical Graduates. July 2020. Accessed May 12, 2022, https://www.nrmp.org/wp-content/uploads/2021/08/Charting-Outcomes-in-the-Match-2020_IMG_final.pdf
- Rajesh A, Asaad M, Chandra A, McKenzie TJ, Farley DR. Outcomes of non-designated preliminary general surgery interns: A 25-year Mayo Clinic experience. Surgery. 02 2020;167(2):314-320. doi:10.1016/j.surg.2019.09.013
- Ritter KA, Anand RJ, Beard K, et al. Impact of Surgery Program Characteristics on Fate of Non-designated Preliminary Surgery Interns. J Surg Educ. 2020 Nov – Dec 2020;77(6):e11-e19. doi:10.1016/j.jsurg.2020.06.001
- Sarosi GA, Silver MA, Ben-David K, Behrns KE. Training outcomes of preliminary surgical residents in a university and Veterans Affairs surgical residency. JAMA Surg. Nov 2014;149(11):1127-32. doi:10.1001/jamasurg.2014.2054
- Moore RA, Rhodenbaugh EJ. The unkindest cut of all: are international medical school graduates subjected to discrimination by general surgery residency programs? Curr Surg. 2002 Mar-Apr 2002;59(2):228-36. doi:10.1016/s0149-7944(01)00644-4
Carolina was born and raised in Lima, Peru, where she completed her medical school training. She is currently a PGY-4 general surgery resident at Beth Israel Deaconess Medical Center in Boston, MA. Recently, she completed a two-year research fellowship at the Program in Global Surgery and Social Change at Harvard Medical School. She is a member of the GME council for Diversity, Inclusion and Advocacy at BIDMC, the DEI committee in surgery and the DEI Task Force at the Association for Surgical Education. At BIDMC, she leads a mentorship program for preliminary residents at BIDMC to help them secure categorical positions. Her interests include abdominal wall reconstruction, surgical education, health systems evaluation and advocacy for diversity and equity in medicine. She enjoys reading, interior design and hanging out with her dog Lucy.