Elderly patients are slightly less likely to die within 30 days of hospitalization if they are treated by doctors who graduated from non-U.S. medical schools, according to a new study by Harvard University researchers.
The findings were published online late last week in the BMJ (formerly known as the British Medical Journal), right in the midst (coincidentally) of the uproar over President Donald Trump’s new immigration restrictions. Those restrictions have raised widespread concern within the medical community, particularly because of their potential effect on the current U.S. doctor shortage. One in four physicians practicing in the United States was born overseas. Many of those foreign-born doctors — particularly primary care physicians, such as internists — work in rural areas or with underserved populations in metropolitan areas.
“America has a history of attracting the best and brightest from around the world and that appears to be true in medicine as well,” said Dr. Ashish Jha, director of the Harvard Global Health Institute and the study’s senior author, in a released statement. “We hope that we are able to maintain that openness because the biggest beneficiaries of these doctors coming to the U.S. have been the American people.”
As background information in the study point outs, foreign-trained doctors are often viewed by American patients as providing a lower quality of care than doctors trained in the U.S., despite a lack of good evidence to support that bias.
This new study is the first to compare patient outcomes of U.S. and foreign-educated doctors, according to its authors.
For the study, the Harvard researchers analyzed more than 1.2 million hospital admissions of Medicare patients aged 65 and older (average age: 80 years) who were admitted to a hospital for a medical condition from 2011 through 2014. Those patients were treated by 44,227 general internists, of whom about 44 percent were trained outside the U.S. The eight countries with the largest number of international medical graduates were India, Pakistan, Philippines, Syria, Nigeria, Mexico, Egypt and China.
The researchers looked at the 30-day death rates for the patients who were treated by U.S.-educated internists and compared them with the rates for the patients who received their care from the foreign-educated ones. The most common causes of death were sepsis, pneumonia, congestive heart failure and chronic obstructive pulmonary disease.
They found a small but statistically significant difference in the death rates: 11.6 percent of the patients treated by the U.S.-educated doctors died with 30 days of hospitalization compared with 11.2 percent of those treated by international graduates.
That difference held even after adjusting for the patients’ age, severity of illness and the hospitals where they were being treated. Interestingly, the patients of the foreign-trained internists were more likely to be non-white, to be on Medicaid and to have a lower median household income than the patients treated by the U.S.-trained internists. They were also more likely to have more than one chronic medical condition, such as diabetes and heart disease.
“Based on the risk difference of 0.4 percentage points, 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,” the researchers write.
Jha and his colleagues offer several possible explanations for the study’s findings. Foreign-trained doctors usually do two medical residencies: one in their home country and one in the United States. That longer period of training may help them perform better, say the researchers.
In addition, landing a medical residency in the United States is much more difficult for non-U.S. graduates. It may be that the foreign-trained doctors who receive those coveted posts are among the best in their country of origin.
“It is also possible that the international graduates might be more concerned about professional failure, and therefore are more engaged in continuous training and updating their skills and knowledge base,” the Harvard researchers write.
Limitations and implications
Of course, this study has several limitations. For example, although 30-day death rates are widely accepted as a measure of quality of care, the study did not look at other measures, including patient experience. Also, the clinical difference in patient death rates between the U.S.- and foreign-trained doctors is quite modest.
So the results should not be interpreted as meaning that doctors trained abroad are superior to their U.S.-trained counterparts.
But the study may help lay to rest the bias among some patients against foreign doctors. “We found no evidence that patient outcomes were worse [emphasis added] for those treated by international medical graduates than for those treated by US medical graduates,” the Harvard researchers write.
“Our findings indicate that current standards of selecting international medical graduates for practice in the US are functioning well for at least one important dimension: inpatient outcomes,” they add. “As we consider expanding our physician workforce, these results suggest that systems modeled on the current rigorous approach to incorporate international medical graduates should allow for better access to care and good outcomes.”
FMI: The study can be read in full on the BMJ website.