Variations in geographical distribution of foreign and domestically trained physicians in the United States: 'safety nets' or 'surplus exacerbation'?

In the United States. a debate has existed for decades about whether foreig n-trained physicians (known in the US as 'international medical graduates' or 'IMGs') and US medical graduates (USMGs) have been differentially distri buted such that IMGs were more likely to be found in locales characterized as high in need or medical underservice. This 'safety net' hypothesis has b een countered by the IMG 'surplus exacerbation' argument that IMGs have sim ply swelled an already abundant supply of physicians without any disproport ionate service to areas in need. Through an analysis of the American Medica l Association Physician Masterfile and the Area Resource File, we classifie d post-resident IMGs and USMGs into low and high need counties in each of t he US states, compared the percentage distributions, and determined whether IMGs were found disproportionately in high need or underserved counties. U sing four measures (infant mortality rate, socio-economic status, proportio n non-white population, and rural county designation), we Show that there w ere consistently more states having IMG disproportions than USMG disproport ions. The magnitude of the differences was greater for IMGs than for USMGs, and there was a correlation between IMG disproportions and low doctor/100, 000 population ratios, These findings are shown to exist simultaneously wit h two empirical facts: first, not all IMGs were located in high new or unde rserved counties; second, IMGs were more likely than USMGs to be located in states with a large number of physicians. The juxtaposition of an IMG pres ence in 'safety net' locales and of IMGs' contribution to a physician abund ance is discussed within the context of the current debate about a US physi cian 'surplus' and initiatives to reduce the number of IMGs in residency tr aining. (C) 1999 Elsevier Science Ltd. All rights reserved.