Patients treated by international doctors have lower death rates

In the United States, patient death rates are lower for internationally trained graduates than for graduates from a US medical school, despite international graduates caring for patients with higher rates of chronic conditions, finds a study published by The BMJ today.

The researchers say that current standards of selecting international medical graduates for practice in the US "appear sufficiently rigorous to ensure high quality care."

International medical graduates make up a quarter of the physician workforce in the United States, United Kingdom, Canada, and Australia. Although international graduates are required to pass examinations to practice medicine in the UK and US, concerns have been raised about the quality of care provided by these graduates.

Yet no study has investigated differences in patient outcomes between international medical graduates and US medical graduates using nationally representative data.

So a team of researchers set out to determine whether patient outcomes differ between general internists who graduated from a medical school outside the US and those who graduated from a US medical school.

They analysed a national sample of data for over 1.2 million Medicare beneficiaries aged 65 years or older admitted to hospital with a medical condition in 2011-14 and treated by over 44,000 international or US medical graduates who were general internists.

The primary outcome was 30 day mortality of patients. Secondary outcomes were 30 day readmission rates and costs of care.

Compared with patients treated by US graduates, patients treated by international graduates had slightly more chronic conditions.

After adjusting for factors that could have affected the results (including patient characteristics, physician characteristics, and hospital fixed effects), they found that patients cared for by international graduates had a lower risk of mortality (11.2% v 11.6%) than patients cared for by US graduates across a broad range of clinical conditions.

The researchers say that for every 250 patients treated by US medical graduates, one patient's life would be saved if the quality of care were equivalent between the international graduates and US graduates.

Readmission rates did not differ between the two types of graduates, whereas costs of care per admission was slightly higher for international medical graduates ($1145 v $1098). Further analysis to test the strength of the results made no difference to the overall findings

One possible explanation, say the authors, is that the current approach for allowing international medical graduates to practice in the US may select for, on average, better physicians.

They stress that this is an observational study so no firm conclusions can be drawn about cause and effect. Nevertheless, they say their findings "should reassure policymakers and the public that our current approach to licensing international medical graduates in the US is sufficiently rigorous to ensure high quality care."