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Brief Report
Normalized “medical inferiority bias”and cultural racism against
international medical graduate physicians in academic medicine
Stephen M. Smith, MD
a
,
b
, Vinita Parkash, MBBS, MPH
c
,
d
,
*
a
Department of Laboratory Medicine &Pathobiology at Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
b
Laboratory Medicine and Pathobiology at the University of Toronto, Toronto, Ontario, Canada
c
Yale University School of Medicine, New Haven, CT, USA
d
Yale New Haven Hospital, New Haven, CT, USA
ABSTRACT
Socio-historical barriers remain a concern in Academic Medicine. Regrettably, despite the modern cultural era defined by increased recognition and response to such
issues, widespread covert barriers and misperceptions continue to limit the advancement of many, in particular, international medical graduate physicians (IMGs) who
represent a significant proportion of the US physician workforce. Adversity is experienced in the form of cultural racism, affinity bias, and underrepresentation in
distinct specialties as well as in leadership roles. Often, these unnecessary hardships exacerbate pre-existing discrimination in Academic Medicine, further margin-
alizing IMGs. In this article, we discuss the prevalence of “medical inferiority bias”and the resulting impact on US healthcare, specifying considerations to be made
from a policy perspective.
Keywords: Cultural, IMG, International medical graduates, Medical inferiority bias, Racism
The last several years have seen a reckoning in Academic Medicine
(AcMed) to address the systematic barriers that have limited advance-
ment and equity for women and minorities.
1,2
There is increasing
recognition that socio-historical barriers (e.g. slavery, segregation, edu-
cation and employment discrimination, voter suppression, stereotyping
and prejudice, etc) limit entry to AcMed for minorities. After entry, a
complex interplay of conscious and unconscious biases with attendant
socio-emotional burdens, and devaluation of achievements limits
advancement and causes attrition and underrepresentation in higher
ranks of women and minorities.
1,3
Thus, in addition to efforts to address
the socio-historical entry level underrepresentation in Medicine for
women and minorities, there is effort to improve representation in
upper-levels and to increase opportunity and support at lower ranks for
these groups in AcMed.
2,4
However, one facet of structural discrimina-
tion in AcMed has gone relatively unacknowledged to date: widespread
“medical inferiority bias”and neo-racism against the international
medical graduate physician (IMG).
IMGs –physician graduates of non-US, non-Canadian medical schools
–fill a critical gap in American healthcare delivery and represent ~23%
of physicians nationally and up to 38% in some Northeastern states.
5
International medical graduate physicians disproportionately work in
densely populated, low-income communities and are increasingly
over-represented in primary care and the lowest paying specialties. A
disproportionate number died from COVID-19 from caring for patients.
6
At entry into residency, approximately 60% are foreign citizens (fIMGs),
and 40% are US citizens (US-IMGs)
5
; a plurality of fIMG come from
lower- and middle-income countries, with nearly 40% from four coun-
tries: India (which alone contributes 23%), Philippines, Pakistan, and
Mexico.
5
International medical graduate physicians complete the iden-
tical licensing examination sequence as American medical graduate
physicians (AMGs) and a communication skills test to enter graduate
medical education (GME) training in the US After completion of training,
75% of IMGs join the US workforce, with many joining AcMed, and many
eventually become naturalized citizens.
7
However, despite (often
repeated) US specialty training, the IMG faculty continue to face unjust
barriers to advancement in AcMed, not unlike well-described racial and
gender disparities in this arena.
8
We describe these barriers herein.
Cultural racism and inferiority bias against IMGs: subtle
but prevalent
Historically, overtly,
9
and today, insidiously, physicians, staff, and
patients –no doubt representative of the US population at large –have
questioned the equivalence of IMGs (particularly fIMGs) licensed and
practicing in the US For example, a recent study on assessment of diag-
nostic competency in Maintenance of Certification (MOC) examinations
among American Board of Internal Medicine (ABIM) diplomates included
IMG vs AMG status as the primary measure of “training characteristics”
for a cohort of internists who had necessarily trained and practiced in the
US for at least a decade.
10
Despite GME in an accredited US or Canadian
* Corresponding author. Yale New Haven Hospital, 20 York Street, New Haven, CT, 06510 USA.
E-mail address: vinita.parkash@yale.edu (V. Parkash).
Contents lists available at ScienceDirect
Academic Pathology 10/4 (2023) 100095
Academic Pathology
journal homepage: www.journals.elsevier.com/academic-pathology
https://doi.org/10.1016/j.acpath.2023.100095
Received 15 February 2023; Received in revised form 28 June 2023; Accepted 5 August 2023; Available online xxxx
eISSN2374-2895/©2023 The Authors. Published by Elsevier Inc. on behalf of Association of Pathology Chairs. This is an open access article under the CC BY-NC-ND
license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
program, successful ABIM certification a decade prior, required 2- and
5-year check-ins with ABIM within the decade; state- and institution-
specific mandated licensure/credentialling/continuing medical educa-
tion (CME), and a decade of practice in the US; authors in this study –and
many like it –choose the country of medical training as the defining
source of potential knowledge deficit or incompetence (unsurprisingly,
IMG status was not a factor in physician performance). Surely, after up-
wards of 13 years of training and practice in the US, IMG physicians
should be rightfully and properly categorized, as are their AMG coun-
terparts, as “American Internal Medicine Graduates.”After all, the very
basis of GME, specialty board certification, MOC, and CME is that un-
dergraduate medical education is inadequate to meet the needs of
modern-day, rapidly changing, subspecialty-based practice of medicine.
9
There is overwhelming evidence that IMGs who have undergone GME
training and board certification perform no differently with respect to
patient outcomes from AMGs.
7,11,12
Yet IMGs continue to be perceived as
inferior in medical training and ability (‘medical inferiority bias’) by the
greater North American medical community. This “medical inferiority
bias”permeates medicine at all levels, including the residency-selection
process, job market, and academia.
13–18
Some IMGs are forced to accept
alternative careers.
19
fIMGs, unlike US-IMGs who are culturally “Amer-
ican,”face, in addition, significant cultural racism –the “institutional
domination and sense of racial–ethnic superiority of one social group
over others, justified by and based on allusively constructed markers”.
20
A majority of fIMGs are non-white and face both the usual profes-
sional and socio-cultural transitioning challenges of immigrant physi-
cians and also racialization-transitioning challenges (the adjustment to a
newly acquired minority race status) as they move into practice in the
US.
7,21
Despite selection pressures ensuring that only those with high
adaptive assimilation skills remain as faculty, many traits continue to set
the fIMG faculty visibly apart from like-race culturally US faculty
including accents, verbal and nonverbal cues, and non-US cultural at-
tributes that subject them to prejudice.
21,22
Numerous personal stories of
fIMGs voice more hostile and overt encounters from colleagues, patients,
and staff, and data suggest higher severity of disciplinary actions for
like-transgressions.
23
There is potential intersectionality of fIMG status
with race and gender. Nonwhite, IMG women may face greater disad-
vantage from stereotype bias (“little brown woman”syndrome) than
like-race IMG men and like-race AMG women.
24,25
It is likely that medical inferiority bias is intersectional with af-
finity bias and cultural racism and that it heightens the limitations for
the advancement of IMG faculty in AcMed, especially into academ-
ic–administrative leadership roles.
26
Less than 3% of institutional
leadership roles in the top 10 US medical schools (as ranked by US
News and World Report) are held by IMGs. Professional societies also
show significant underrepresentation of IMGs in leadership roles,
including in subspecialties where IMGs represent a significant plu-
rality, such as pathology or internal medicine.
27
For example, in in-
ternal medicine –afield where 43% of practitioners are IMG –only
11% of residency program directors are IMG.
28
International medical
graduate physicians seem to be largely absent from some national
leadership pipeline programs such as the National Clinician Scholars
Program.
29
Among the most prevalent and insidious communicators of the
“inferiority”of the IMG faculty are the blanket exclusion policies for IMGs
from some post-graduate medical training programs (it is worth noting
that while some programs may choose not to have taken on the expense of
H1b visa sponsorship, J-1 sponsorship occurs through the Educational
Commission for Foreign Medical Graduates (ECFMG) and is not at cost to
a residency program),
30,31
the annual ritualistic secreting of IMG faculty
and trainees from residency applicants,
30
and the celebratory announce-
ment of “matching of all AMGs”.
21,32,33
Beyond creating dissonance for
the IMG faculty with organizational messaging of equity, these practices
delay socialization of AMGs to practicing and working with IMGs and
perpetuate anti-IMG bias.
15,33,34
There is no formal publicly available
data on promotion metrics for IMGs; however, IMGs report discrimination
for advancement.
21,22
Indeed, it is plausible that the differential statistics
for non-advancement of Asian and Hispanic faculty reflect the disadvan-
tage of IMG status, rather than race, as these racial groups within Medi-
cine have high IMG percentage.
35
In fact, immigrant bias maywell explain
the “illusion of Asian success”in science more broadly.
36
Impact of cultural racism and medical inferiority bias on
American medicine
Incongruence between “espoused”and “lived”institutional theoriesis a
significant contributor to organizational malfunction and physician disen-
gagement,
37
factors that directly impact on patient quality and safety, and
institutional financial well-being. Incongruence of diversity between
lower-level faculty and senior leadership rankscreates a sense of lack of
“membership”and “meaning”in work, known factors that contribute to
demotivation, disaffection,and departure fromwork. International medical
graduate physicians report lower career satisfaction in jobs and perceive a
lack of support from colleagues.
38,39
International medical graduate phy-
sicians are generally reconciled with this disadvantaged professional exis-
tence and see it as the “cost of being immigrant”.
38
This may lead IMGs,
expecting diminishment and non-advancement, to choose to concentrate
their efforts to job-aspects with greater likelihood of success, e.g. publica-
tion efforts. This prioritization of selfish “generalizable capital”over in-
vestment in “organizational capital”(e.g. teaching medical students,
participating in inclusivity work, supporting junior faculty) may be to the
detriment of the parent organization. It reduces the individual’scommit-
ment to organization-building and increases the likelihood that competing
organizations will successfully draw this individual away from their exist-
ing organization. Indeed, AcMed may need to consider whether the lack of
equity and inclusivity for fIMGs might translate to early withdrawal from
the workforce and possible emigration to the fIMGs to their native country
for practice and retirement (the so-called “reverse brain drain”effect).
40,41
Two factors need greater consideration. Although AcMed has
committed to greater inclusivity, it faces an opposing force that un-
dermines an inclusive institutional culture. Market-force-driven mergers
and increasing subspecialization create fragmentation, which requires
adopting increasingly hierarchical structures to get work done. This often
requires organizations to propose “organizational cultures”that neces-
sarily adopt values of the majority social culture, which, unfortunately is
not as inclusive of immigrants and minorities and views many non-
majority cultural traits as negatives.
15
Given that middle management
–including in medicine –is largely locally drawn and US-born, the risks
of sociocultural incompatibility or intolerance are greater.
42,43
This can
result in greater disaffection and disengagement of minority workers.
Thus, there needs to be a focused effort to ensure equity of opportunity
and inclusivity for all, with consideration given to the overvaluation of
the so called “soft skills”of management.
Second, and at a national level, consideration needs to be given to the
distribution of IMG slots for residency. Discriminatory practices at entry
into residency are a complex mix of several factors: (1) protectionism for
the AMG –US citizens, perceived as the brightest and in whom the
country has already invested so much;
15,44
(2) difficulty in accurately
evaluating the medical competency of someone from a lower- or
middle-income country;
45
and (3) concerns about socio-cultural compe-
tencies in the work place and with patients.
46,47
Thus, selective residency
programs simply follow a seeming risk-mitigation strategy of excluding
IMGs from consideration. This strategy, which is at least partially based
in cultural racism and IMG inferiority bias, de facto segregates IMGs into
certain specialties and practice environments. Some specialties now
show large plurality fIMG (e.g. 40.4% of fellows in endocrine, diabetes
S.M. Smith, V. Parkash Academic Pathology 10/4 (2023) 100095
2
and metabolism [(2021 match], and 30.2% of entering residents in pa-
thology [2023 match]).
48,49
This may not be of any consequence; how-
ever, it is worth noting that cultural divides in science are often the
foundation for, a direct symptom of, and continued promoter of classism,
intra- and extra-community distrust, physician marginalization, and lack
of support for a given field.
50
Intersectionality: cultural racism compounds other
discriminatory factors in academic medicine
AcMed should consider multiple factors that marginalize the work-
force, not only because it impacts productivity but indeed because it is
innately unethical to ignore these factors. Homo sapiens are a complex
and diverse species: arising from extreme backgrounds of varied socio-
economic status; genetically common yet showing variable phenotypes
from birth onwards; nurtured by various mores and cultural identities;
engaging with the world in a myriad of experiences; and developing
arrays of opinions and personalities rooted in both the norm and absurd.
One-size-fits-all solutions often do not work for this species known for
advanced complex thought and reason. Particularly in AcMed –a
marketplace of free ideas within medicine which seeks to drive knowl-
edge by embracing novel thinking –we should embrace the elements of
diversity that we contend are central to the advancement of thought.
Regretfully, this is simply not the case. In fact, the effects of exclusion
are more severe with increasing differentiating factors for a given
physician. Female physicians are markedly under-represented in AcMed
and leadership roles, even in the modern era.
51
Gendered agism termi-
nates women's options prematurely.
52
But imagine being an fIMG who
must adjust with the aforementioned issues, compounded with being a
female and/or of age? Forget representation in leadership roles or AcMed
–basic elements of respect are often noted. It is challenging to create a
“level playing field”for all physicians when those making decisions on
the national level as well as the individual hospital level are of the same
predictable, redundant demographic.
Conclusion
Should AcMed and legislative institutions seek IMG equality? Would
requisite distribution of IMG residency slots across specialties and pro-
grams be a significantly unfair imposition? We know that the US
healthcare system will be comprised of 40% of these physicians, after all.
Addressing the disparity would certainly be beneficial in providing the
much-needed diversity for certain specialties, such as dermatology. It
may also be generally beneficial for patients as America embraces
increasing immigration from low- and middle-income countries to offset
the demographic deficit secondary by an aging population. These dis-
cussions will need thoughtful consideration.
However, at least as a start, it is imperative that broader academia
stops treating IMGs as second-class physicians. Faculty, particularly IMG
faculty in departments that categorically refuse IMG applicants for
various positions, need to question this behavior. This is not to argue that
departments actively or even consciously are quelling the advancement
of IMGs –a glance at any given department's website will surely yield a
statement of diversity and cultural embracement. But the follow-through
of these statements does not match the reality of experiences of IMGs in
AcMed. Institutional and organizational introspection is necessary.
Change begins with engagement of IMGs and recognizing and embracing
the critical role that they play, not just at the national “numbers”level.
Declaration of competing interest
The authors have no conflicts of interest to report.
Funding
This research received no specific grant from any funding agency in
the public, commercial, or not-for-profit sectors.
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