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Physicians: The Shrinking Pool Of International Medical Grads
by Carl Shusterman

Would it surprise you to learn that the number of IMGs who registered for USMLE Parts I and II have fallen by over 55% during the past four years? That non-U.S. citizen IMG participants in the Match fell by more than 36% between 1997 and 2001? And that the ECFMG sponsored over 23% less IMGs for J visas between 1995 and 2000?

Each of these percentages came straight from the Educational Commission for Foreign Medical Graduates (ECFMG) and from the National Resident Matching Graduates. See our "Physicians Page" at

and scroll down to "Articles" and click on "The Shrinking Pool of International Medical Graduates (PDF File)."

The question is why the number of IMGs coming to do medical residencies in the U.S. is decreasing, and what implications this has for medically-underserved areas across the U.S.?

The second part of the question can be easily answered by referring to the recent federally-funded report by the Sheps Center at the University of North Carolina. See "If Fewer IMGs Were Allowed In The U.S., Who Would Replace Them? (PDF File)." which may also be found in the "Articles" section of our "Physicians Page." We summarized the Shep's Report in the August 2001 issue of SHUSTERMAN'S IMMIGRATION UPDATE at

It is clear that if the supply of foreign-born physicians practicing in medically underserved areas were significantly decreased, this would have disastrous consequences for the health of citizens living in the 30% of the rural counties in the United States which has been declared medically underserved by the federal government.

Why is the supply for IMGs obtaining J-1 status to do medical residencies steadily decreasing? One reason is the requirement that IMGs, but not U.S. medical school graduates, take the Clinical Skills Assessment (CSA) examination as a condition of applying for a medical residency program.

The CSA costs $1,200, a princely sum for a recent medical school graduate, much less a physician practicing in a third-world country. Also, unlike USMLE I and II which are offered worldwide, the an applicant for the CSA must travel to Philadelphia, Pennsylvania, the one and only testing site in the world for the examination. And to make matters worse, we have heard that such IMGs have been refused visas to enter the U.S. in order to take the CSA. Our views about the CSA were expressed in the April 1998 issue of SHUSTERMAN'S IMMIGRATION UPDATE under the title "IMGs to Join the Endangered Species List?" See

An article in the September 2001 issue of ACP-ASIM (American College of Physicians-American Society of Internal Medicine) Observer speculates that another reason for the decline in IMGs entering the U.S. on J waivers is a shortage of job opportunities in medically-underserved areas. If this is true, we have yet to notice this trend. The latest list of HPSAs, MUAs and MUPs on our "Physicians Page" does not seem to have contracted while the most recent "USDA List Of HPSAs Fully Medically Served (8-13-01)" has expanded during the past six months. See

In any case, the ACP-ASIM article should ring alarm bells for Members of Congress representing medically underserved constituencies. The article may be found on our "Physicians Page" at

by scrolling down to "Articles" and clicking on "A Coming Shortage Of Foreign-Trained Doctors."

How can this situation be remedied? A number of recommendations spring to mind: (1) Abolishing the CSA, or at the very least, applying it to both foreign and U.S. medical graduates, and establishing testing centers worldwide; (2) The State Department should instruct posts to issue visitor's visas to IMGs registered to take the CSA in Philadelphia; and (3) Supporting the "Rural and Urban Health Care Act" (S.1259) and (H.R.2705) which would allow the states to sponsor 40 rather than 20 IMGs for J waivers annually. See our "RN Page" at

and scroll down to "Rural and Urban Health Care Act of 2001" for more information about these bills.

In a country faced with a growing threat of bioterrorism, no U.S. citizen should lack access to a physician.

About The Author

Carl Shusterman is a certified Specialist in Immigration Law, State Bar of California
Former U.S. Immigration & Naturalization Service Attorney (1976-82)
Board of Governors, American Immigration Lawyers Association (1988-97)
Phone: (213) 623-4592 Fax: (213) 623-3720
Law Offices of Carl Shusterman, 624 So. Grand Ave., Suite 1608
Los Angeles, California 90017

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