New study urges enhanced recruitment strategies to help address US primary care physician shortages

Finding sound strategies to meet the growing demand for primary care, especially in underserved areas, is an ongoing public health challenge among policymakers. A new study led by the Harvard Pilgrim Health Care Institute suggests that policy interventions aimed at recruiting physicians to specialize in primary care, especially to practice in underserved areas, should be tailored to the citizenship status of international medical graduates (IMGs).

The findings are published October 15 in Journal of General Internal Medicine.

IMGs, or those who graduated from a medical school located outside the U.S. and Canada, now make up a quarter of all licensed physicians in the U.S. This population has been shown to specialize in primary care at a higher rate than U.S. medical graduates, especially in underserved areas across the country. However, their citizenship status, which differentially affects their ability to enter and remain in the U.S. after medical school, can impact which specialties they enter and where they ultimately practice medicine.

“IMGs have made significant contributions to the U.S. health care system, as they are more likely to work in high-need, underserved areas,” says Tarun Ramesh, lead author of the study and research fellow at the Harvard Pilgrim Health Care Institute. “Because various factors threaten their ability or wish to continue their contributions, it’s crucial that we understand how their citizenship status impacts which specialty and practice location they choose to better aid policymakers in adapting interventions to incentivize entering primary care practice, especially in rural and shortage-facing areas.”

Researchers studied 15,133 new physicians who accepted a job offer from 2010 to 2019 using the New York Resident and Fellows Exit Survey. The study sample included 8,177 U.S. medical graduates; 2,753 U.S. citizen IMGs; 1,057 permanent resident IMGs; and 3,146 noncitizen non-permanent resident IMGs. The study assessed three distinct outcomes: whether a new physician chose to practice primary care; whether a new primary care physician chose to work in a rural area; and whether a new primary care physician chose to work in a health professional shortage area.

The team found that citizenship status has significant effects on IMGs’ choices of specialties and practice locations, confirming that the role played by IMGs in the US health care system differs by their citizenship status. Compared to U.S. medical graduates, the team found that US citizen IMGs were five times, permanent resident IMGs seven times, and noncitizen non-permanent resident IMGs nine times more likely to enter primary care compared to US medical graduates. They also identified two distinct trends: a declining proportion of noncitizen non-permanent resident IMGs entering primary care and increased likelihood of their practicing in rural areas and health professional shortage area.

“The role that IMGs play in bolstering health care options in underserved areas shouldn’t be overlooked,” said senior author Hao Yu, Harvard Medical School associate professor of population medicine at the Harvard Pilgrim Health Care Institute. He adds, “While visa incentive programs may drive non-citizen, non-permanent resident IMGs to practice in these areas, our findings show that more nuanced efforts are needed to make primary care a more attractive specialty.”

The authors suggest that further research is needed to better understand differences in subspeciality, salaries, job satisfaction, and incentives among U.S. citizen, permanent resident, and noncitizen non-permanent resident IMGs, in addition to evaluating new state laws offering provisional licensing pathways for IMGs to practice medicine.