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Med Care. 2004 Aug;42(8):747-55.

The impact of international medical graduate status on primary care physicians' choice of specialist.

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Robert Wood Johnson Clinical Scholars Program, The Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA.



Approximately one fourth of practicing physicians in the United States graduated from medical schools in other countries. It is unknown how the role of international medical graduate status affects physician decision-making.


The objective of this study was to determine whether a primary care physicians' knowledge of a specialist's international medical graduate status affects his or her decision to refer patients to that specialist.


We studied a national, cross-sectional study of primary care physicians who see adult patients. The sample was drawn from the American Medical Association Physician's Professional Data. Each physician received 2 clinical case vignettes describing a patient for whom referral to a specialist was considered necessary. Each vignette was followed by 5 vignette specialist descriptions with medical school graduate status varied randomly alongside other physician characteristics.


We measured the decision to refer to an international versus U.S. medical graduate specialist.


Of 1054 eligible physicians, 623 (59.1%) responded. Respondents were significantly more likely to refer to a U.S. medical graduate (USMG) compared with an international medical graduate (IMG) (63% vs. 54%, P <0.05). After adjustment for age, race, sex, and referral characteristics of the vignette specialists, a positive referral decision was noted in a higher proportion of vignettes in which the vignette specialist was described as a USMG versus an IMG (63% vs. 51%, P <0.05).


With other factors being equal, vignette specialists described as IMGs versus USMGs were significantly less likely to be associated with a positive referral decision. Although specialist IMG status, relative to other factors, might not have a major effect on referral decisions, it is possible that negative views of international medical graduates could lead to suboptimal choices in referral decisions. Potentially, a patient could be referred to an USMG who happens to have inferior clinical skills than an IMG with superior clinical skills.

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