Patients in US hospitals treated by general internists who graduated from foreign medical schools had slightly lower mortality than those treated by internists who graduated from US medical schools, according to data published in the BMJ.

Yusuke Tsugawa, MD, MPH, PhD, from the Department of Health Policy and Management at the Harvard TH Chan School of Public Health in Boston, and colleagues conducted an observational study using data from older Medicare patients to determine any differences in patient outcomes between general internists who graduated from a medical school outside the United States and those who graduated from a US medical school.

The study included a 20% national sample of data for Medicare fee-for-service beneficiaries older than 65 years of age who were admitted to the hospital between 2011 and 2014 and who were treated by an international or US medical graduate. A total of 1,215,490 hospital admissions were included in the analysis, treated by 44,227 general internists.

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The overall 30-day mortality rate was 11.4%. Patients who were treated by international graduates had a lower adjusted mortality rate, compared with those treated by US graduates (11.1% vs 11.7%; adjusted odds ratio, 0.94). The data were consistent after additional adjustment for physician characteristics and after the researchers compared the international graduates with US graduates within the same hospital.

The investigators note that the differences in patient mortality were not explained by differences in length of stay, spending level, or discharge location.

In addition, the cost of care was slightly higher for patients treated by international graduates than by US graduates ($1,145 vs $1,098; adjusted difference $47).

Patients treated by international graduates also had higher adjusted readmission rates than patients treated by US graduates (15.9% vs 14.9%; adjusted odds ratio, 1.08). However, the readmission rates did not differ between the graduates after the researchers compared international and US graduates within the same hospital, suggesting that international graduates tend to practice in hospitals with higher readmission rates.

“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,” the study authors wrote. “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.”


  1. Tsugawa Y, Jena AB, Orav EJ, Jha AK. Quality of care delivered by general internists in US hospitals who graduated from foreign versus US medical schools: observational study. BMJ. 2017. doi: 10.1136/bmj.j273