The arrival of international medical graduates (IMGs) on U.S. shores is not a relatively recent phenomenon. For the past century, there has been a steady stream of IMGs into the country’s health care system, according to Jambur Ananth, M.D., this year’s winner of the APA George Tarjan Award.

The influx of IMGs was accelerated when roughly 5,000 to 7,000 trained physicians, mostly Jewish, fled to the United States from European countries threatened by National Socialism, said Ananth at APA’s 2000 annual meeting in May in Chicago. Ananth is a professor of psychiatry and director of the psychopharmacology unit at the University of California, Los Angeles, and clinical director of adult psychiatric services at the Harbor UCLA Medical Center.

Since the passage of the U.S. Information and Education Exchange Act in the early 1960s, there has been an increase in the pace at which IMGs have come to the U.S. and the diversity of countries from where they hail.

IMGs made up slightly more than 10 percent of the physician workforce in the U.S. in 1963 and 18 percent in 1970. The AMA master file published in 1999 indicates that IMGs now make up about 23 percent of the physician workforce.

Ananth reported that IMGs have typically concentrated in specialties such as internal medicine, pediatrics, and psychiatry. The number of IMG psychiatrists has increased from 15,000 in 1985 to 39,000 in 1997.

According to Ananth, who is also a member of APA’s Committee on IMGs, IMGs also came to the U.S. in large numbers to fill a shortage of medical manpower. While the shortage was experienced by all specialties, psychiatry was affected to the greatest degree. Shortages of medical manpower usually affect the sickest and poorest segments of the population, he emphasized, so the influx of IMGs into the U.S. health care system restored balance to the field of medicine in terms of treating the underserved.

Ananth cited a number of studies that confirmed the presence of higher concentrations of IMGs in areas of high infant mortality rates, low socioeconomic status, and highly concentrated elderly populations. For instance, Nishi and Wang noted in 1995 that health care professionals of Asian origin were concentrated in the inner cities, and over half were concentrated in what were considered to be the poorer sections of the cities.

Blanco and colleagues, using data from the 1996 National Survey of Psychiatric Practice, compared the practice patterns of IMGs and graduates of U.S. medical schools. They found that IMGs worked longer hours, spent more time working in the public sector, and treated a higher proportion of psychotic patients. They concluded that policies aimed at decreasing the number of IMGs in turn decrease the number of psychiatrists available to treat minorities and other underserved populations. The AMA’s 1993 Survey of Graduate Medical Education found that IMGs are three times as likely as their U.S. counterparts to practice in poorer areas of the country.

Why is there a difference in practice patterns between IMGs and USMGs? Ananth believes that part of the answer is the result of legal measures that have stimulated IMGs to take advantage of practice opportunities in critically underserved communities.

Historically, IMGs have made important academic contributions to the development of psychiatry. In the 1930s a number of psychoanalytic psychiatrists came to the United States and wielded a profound and lasting influence on American psychiatry. Earlier in American history, Benjamin Rush, considered to be the father of American psychiatry, graduated from a medical school in Scotland. Adolf Meyer, the "American Kraepelin" whose psychobiological approach dominated American psychiatry for 50 years, was also an IMG from Zurich. In addition, there are many current and recent chairs of psychiatry who are IMGs. Peter Whybrow, M.D., Matcheri Keshevan, M.D., and Dilip Jeste, M.D., to name just a few, are well known for their work on bipolar disorder, psychopharmacology, and schizophrenia, respectively.

Ananth quoted an experienced residency director in summing up the invaluable contributions of IMGs to psychiatry. "IMGs bring a diversity of talents and a much-needed, low-tech clinical perspective to American medicine. They provide a glimpse of the world beyond. Culturally, they have enriched our value system and psychotherapeutic armamentarium and assisted in helping patients."

Ananth believes that "IMGs have a better understanding of the value systems of different cultures, and thus they can assess cultural deviations and psychopathology and not label deviations as psychopathology, but as uniqueness."