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CardioNerds (Amit Goyal and Daniel Ambinder) join fellow lead, Dr. Giselle A. Suero-Abreu (FIT, Massachusets General Hospital), Dr. Isadora Sande Mathias (FIT, Houston Methodist and CardioNerds Academy Fellow), and Dr. Victor Nauffal (FIT, Brigham and Women’s Hospital) for a discussion with Dr. William Zoghbi (Chair, Department of Cardiology, Houston Methodist Hospital, Methodist DeBakey Heart & Vascular Center, Past President, the American College of Cardiology) about international medical graduates in the cardiology workforce. This episode focuses on the narratives of international medical graduates (IMGs) who make important contributions to the US medical workforce and scientific innovation. Listen to the episode to learn the state of IMGs in the US physician workforce and the field of Cardiology, an overview of factors that influence IMG selection when applying to residency and fellowship training programs in the US, the impact of recent changes in licensing exams and immigration restrictions, and how to address challenges and support IMGs throughout their medical careers. Audio editing by CardioNerds Academy Intern, Dr. Leticia Helms.
Claim free CME just for enjoying this episode! Disclosures: None
Show notes
1. What is the definition of an international medical graduate (IMGs)?
- International medical graduates (IMGs) are physicians who who graduated from a medical school outside the United States, regardless of nationality.
- This group of foreign-trained physicians include US-IMGs (US citizens) and non-US IMGs (non-US citizens). Nearly 80% of IMGs are born abroad [1].
- In a paper senior authored by Dr. Zoghbi, IMGs in the US physician workforce are described as “the multicultural, multiethnic, open-minded, and plural fabric that has defined American medicine and contributed to its success over the years” [2].
2. Why are IMGs important?
- IMGs are an integral part of the U.S. healthcare system. They constitute about 25% of the physician workforce and, since 2010, the number of IMGs in practice has grown by nearly 18% [1, 3].
- IMGs play a critical role in addressing healthcare inequities across the US, comprising a significant proportion of physicians in high-need rural and underserved urban areas [1, 3, 4].
- IMGs contribute to the diversity and cultural competence in the US physician workforce with 98% of them speaking two or more languages fluently. They help patients overcome linguistic and cultural barriers that can interfere with their care [5]. Learn more about Diversity and inclusion (Episode 95) and Latinx representation in cardiology (Episode 129).
- Racial and ethnic concordance between physicians and their patients results in improved healthcare outcomes, and IMGs are essential in matching the needs of the increasingly diverse US population [6].
- Many IMGs pursue the opportunity to train in the best academic programs in the US and return as leaders to serve their country. This becomes an avenue for international collaboration to help patients and contribute to research, innovation, and education.
3. What is the state of the IMG workforce in Cardiology?
- IMGs in cardiology serve as an important source of cardiac care in the United States.
- Data from the 2020 Physician Specialty Data Report from the Association of American Medical Colleges (AAMC) [7] showed that:
- Among active US physicians, IMGs comprise 31% of general cardiologists, 46% of interventional cardiologists, and 26% of pediatric cardiologists.
- Among ACGME trainees, IMGs constitute 38% of fellows in cardiovascular disease, 53% in interventional cardiology, and 20% in pediatric cardiology.
- Many IMGs have non-immigrant visas, including the J-1 Visitor Exchange visa, and pursue visa waivers at the end of their training. This provides an important source of care to patients in rural and underserved urban areas but can also pose restrictions that affect the career choices and post-training employment opportunities of these physicians [4, 8].
- For example, only a third of visa waiver positions can go to specialists, creating difficulty for highly trained cardiovascular subspecialists who are IMGs (such as interventionalists and electrophysiologists) who sometimes have limited options to find a job that matches their training when integrating into the US cardiology workforce [4].
4. What are some challenges IMGs face?
- IMGs face a series of barriers when entering US residency programs, during their training experiences, and upon the transition into practice [2, 4, 8-11].
- There are disparities and biases concerning IMGs during the residency and fellowship match process. For instance, data from the 2020 NRMP Program Director survey showed that 36% of program directors would “seldom” interview a non-US IMG and 18% would “never” do so. When ranking non-US IMGs, 37% of program directors would “seldom” and 21% would “never” do so [12]. These numbers have remained similar over recent years.
- Over the past few years, changes related to licensing exams, immigration policies, and the COVID-19 pandemic have impacted the recruitment and integration of IMGs into the US physician workforce [2, 8, 11]
- Nearly 15,000 IMGs in active clinical practice in the US are awaiting permanent residency status. This limits their ability to work to the fullest capacity and capability, especially during public health emergencies [13].
- Understanding the challenges faced by IMGs can inform efforts to strengthen support and guidance for this resilient and hard-working group of physicians.
5. How can we support IMGs throughout their medical careers?
- There are many opportunities for addressing the professional and personal challenges faced by IMGs and supporting their integration throughout their medical careers (Table 1) [4, 5, 10, 11].
- Discussion among program leadership at different institutions can help administrators learn from each other’s experiences regarding the recruitment and retention of IMGs and may help reduce barriers.
- Major medical organizations and the cardiology community can help address immigration and licensure policies affecting IMGs during training and when transitioning to the cardiology workforce in the US [2, 4, 13].
- Incorporating diversity and inclusion efforts into the mission of organizations is paramount to ensuring professional satisfaction and success for IMGs as academic faculty.
- Advocacy, mentorship, and sponsorship enable IMGs to contribute to their highest potential in their medical careers in the US and internationally.
Figure 1. Arjun et al [10] 
Table 1. (Zaidi, Z. et al) [5]
The CardioNerds Narratives in Cardiology series features cardiovascular faculty representing diverse backgrounds, subspecialties, career stages, and career paths. Discussing why these faculty chose careers in cardiology and their passion for their work are essential components to inspiring interest in the field.
Each talk will feature a cardiology faculty from an underrepresented group, within at least one of several domains: gender, race, ethnicity, religion, national origin, international graduate status, disadvantaged backgrounds, etc.
Featured faculty will also represent a variety of practice settings, academic ranks, subspecialties (e.g. clinical cardiology, interventional cardiology, electrophysiology, etc), and career paths (e.g. division chief, journal editor, society leadership, industry consultant, etc).
Faculty will be interviewed by fellows-in-training for a two-part discussion that will focus on:
1) Faculty’s content area of expertise
2) Faculty’s personal and professional narrative
As part of their narrative, faculty will discuss their unique path to cardiology and their current professional role with particular attention to challenges, successes, and advice for junior trainees. Specific topics will be guided by values relevant to trainees, including issues related to mentorship, work-life integration, and family planning.
To help guide this important initiative, the CardioNerds Narratives Council was founded to provide mentorship and guidance in producing the Narratives series with regards to guests and content. The CardioNerds Narratives Council members include: Dr. Pamela Douglas, Dr. Nosheen Reza, Dr. Martha Gulati, Dr. Quinn Capers, IV, Dr. Ann Marie Navar, Dr. Ki Park, Dr. Bob Harrington, Dr. Sharonne Hayes, and Dr. Michelle Albert.
The Narratives Council includes three FIT advisors who will lead the CardioNerds’ diversity and inclusion efforts, including the current project: Dr. Zarina Sharalaya, Dr. Norrisa Haynes, and Dr. Pablo Sanchez.
Guest Profiles – Physician Scientists Women Electrophysiology
Dr. William A. Zoghbi, a renowned cardiology, echocardiography and cardiac imaging expert, has developed noninvasive heart function and valve disorder evaluation techniques. As a result, Dr. Zoghbi has overseen national and international heart valve evaluation guideline development.He built his reputation on his ischemic heart disease, myocardial function and hibernation research, as well as his development of echocardiographic techniques to evaluate valvular dynamics and measure valvular regurgitation. Dr. Zoghbi has authored more than 300 publications and lectured at every major cardiology conference worldwide.
Dr. Giselle Alexandra Suero Abreu is a cardiology fellow at Massachusetts General Hospital. She was born and raised in Dominican Republic where she received her M.D. from the Instituto Tecnológico de Santo Domingo (INTEC). During medical school, she discovered a passion for research and then attended New York University School of Medicine where she pursued a MSc in biology, physiology and neuroscience and then a PhD in biomedical imaging. During her PhD, she studied angiogenesis and tumor development in cancer models using multimodality molecular imaging. She went on to complete an internal medicine residency at Rutgers University New Jersey Medical School and is currently completing a chief resident year. She plans to pursue a career as a physician-scientist in the fields of cardio-oncology and cardiac imaging, and is interested in furthering diversity in academic medicine.
Dr. Victor Nauffal is a Clinical Fellow in the Division of Cardiovascular Medicine at the Brigham and Women’s Hospital. He was born in Sydney, Australia and earned his medical school degree from the American University of Beirut. He completed his internal medicine training at the Osler Housestaff Training Program at the Johns Hopkins Hospital. He will be pursuing subspecialty training in cardiac electrophysiology. His research efforts in cardiovascular epidemiology are focused on the intersection of genetics and cardiac arrhythmias. In his free time he enjoys skiing and playing basketball.
Dr. Isadora “Isa” Sande Mathias is a cardiology fellow at Houston Methodist Hospital and completed internal medicine residency at the Cleveland Clinic. She was born and raised in the diverse city of Salvador de Bahia, Brazil, where she completed her medical school in 2017. Isa has always been upbeat, outgoing, making friends everywhere, and thus interested in connecting with people from different backgrounds and cultures, and that combined with a strong passion for cardiology and education attracted her to CardioNerds. In her free time, she likes to cook and try new restaurants, run, hike and practice yoga outdoors, and spend time with her cat Caju.
References
1. Ahmed, A.A., et al., International Medical Graduates in the US Physician Workforce and Graduate Medical Education: Current and Historical Trends. J Grad Med Educ, 2018. 10(2): p. 214-218.
2. Kalra, A., P.K. Shah, and W.A. Zoghbi, Travel Bans and Threats to US Health Care-Our Hearts Are at Stake. JAMA Cardiol, 2017. 2(4): p. 351-352.
3. Murphy, B. How IMGs have changed the face of American medicine. 2020.
4. Zoghbi, W.A., et al., Working group 4: International medical graduates and the cardiology workforce. Journal of the American College of Cardiology, 2004. 44(2): p. 245-251.
5. Zaidi, Z., M. Dewan, and J. Norcini, International Medical Graduates: Promoting Equity and Belonging. Acad Med, 2020. 95(12S Addressing Harmful Bias and Eliminating Discrimination in Health Professions Learning Environments): p. S82-s87.
6. Institute of Medicine Committee on, U., R. Eliminating, and C. Ethnic Disparities in Health, in Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care, B.D. Smedley, A.Y. Stith, and A.R. Nelson, Editors. 2003, National Academies Press (US)
Copyright 2002 by the National Academy of Sciences. All rights reserved.: Washington (DC).
7. 2020 Physician Specialty Data Report. Active physicians who are international medical graduates (IMGs) by specialty. . [cited 2021 June 22, 2021]; Available from: https://www.aamc.org/data-reports/workforce/interactive-data/active-physicians-who-are-international-medical-graduates-imgs-specialty-2019.
8. Fanari, Z., Effect of Changes in Visa Policies and Procedures on Fellows-in-Training and Early Career Cardiologists. J Am Coll Cardiol, 2017. 69(25): p. 3115-3117.
9. Chen, P.G.-C., et al., Professional Challenges of Non-U.S.-Born International Medical Graduates and Recommendations for Support During Residency Training. Academic Medicine, 2011. 86(11): p. 1383-1388.
10. Kanwal, A., G. Sharma, and E. Surkova, The Assimilation of International Medical Graduates Into the Cardiovascular Workforce. JACC: Case Reports, 2020. 2(3): p. 508-512.
11. Khan, M. and V. Madaan, New Ways to Support the Recruitment of International Medical Graduates During the Pandemic. Academic Medicine, 2021. 96(5): p. 616.
12. Results of the 2020 NRMP Program Director Survey. June 2021]; Available from: https://www.nrmp.org/main-residency-match-data/.
13. Nagarajan, K.K., et al., Prevalence of US-trained International Medical Graduates (IMG) physicians awaiting permanent residency: a quantitative analysis. J Community Hosp Intern Med Perspect, 2020. 10(6): p. 537-541.
Amit Goyal, MD 
Daniel Ambinder, MD
