Possible Discrimination in Recruitment of Psychiatry Residents?

The issue of the work force and international medical graduates in American medicine (1–5) and psychiatry (6) has been the subject of discussion by many health care analysts, who have warned of a surplus of physicians due to a greater presence of international medical graduates. The percentage of international medical graduates in the U.S. health care work force has been steadily increasing (1). The perspective of an oversupply of physicians has led some experts to assert that “only by reducing the number of graduating residents to 110% of the current number of graduates of U.S. medical schools.will the supply of physicians be brought into line with staffing requirements by 2010” (2). However, not all health care manpower experts agree with these dire predictions. According to some (3, 4), the existing surplus is small. The surplus is also likely to be modest within the next 15 years, after which it will recede. In addition, all surpluses are local and regional.

While there is no general consensus about physician supply and demand in the United States, the issue of international medical graduates in American medicine has become a politically charged problem. However, politicians in general are not enthusiastic about addressing the overall question of physician supply, including the number of residents (5).

There is some evidence that medicine has attempted to address this issue through various measures, including limiting the access of international medical graduates to residency positions. According to a General Accounting Office report (7), “Most states require that foreign medical school graduates pass a different licensure examination and complete more years of postgraduate (residency) medical training than their U.S. counterparts.” In psychiatry, the percentage of international medical graduates who reported association with the American Board of Psychiatry and Neurology as a consultant, a director, or an examiner fell considerably below the percentage of international medical graduates in a general sample (8).

The purpose of this study was to examine whether residency training programs in psychiatry favor U.S. medical school graduates over international medical graduates during the initial phase of the recruitment process.

METHOD

Two letters that requested an application form for a psychiatry residency position were sent to 193 adult psychiatry programs. Letters were not sent to residency training programs in Michigan, since the persons who were requesting applications were residents currently enrolled in one of the Michigan programs (this was not stated in the letters). The letters differed in only two respects: the names of the writers (one American and one Pakistani) and the medical schools from which they graduated (Wayne State University School of Medicine and King Edward Medical College, Lahore, Pakistan). Letters were sent 1 week apart during August and September 1996. Return addresses for both letters were from southeastern Michigan.

Continuity-corrected McNemar's chi-square tests for paired data were used for two statistical analyses of responses to the request for an application for residency training. The first analysis included any kind of response, including statements such as “We do not take any international medical graduates” or an application form with further requirements for international medical graduates. The second analysis included only responses with application forms and no differences in requirements.

RESULTS

Five programs responded that they were closed. Of the remaining 188 programs, 159 responded to the U.S. medical school graduate applicant. The international medical graduate applicant received 105 responses, including the responses with no application form or with further requirements for international medical graduates. Ninety-nine programs responded to both applicants, 60 to the U.S. medical school graduate only, six to the international medical graduate only, and 23 to neither. This difference was statistically significant (χ²=42.56, df=1, p<0.001; proportion in agreement=0.65).

When only the responses with application forms and no difference in requirements were counted, the U.S. medical school graduate received 159 responses and the international medical graduate received 87 responses. Eighty-one programs responded to both, 78 to the U.S. medical school graduate only, six to the international medical graduate only, and 23 to neither. This difference was also statistically significant (χ²=60.01, df=1, p<0.001; proportion in agreement=0.55).

Examples of qualitatively different responses to the international medical graduate included statements such as “We do not take international medical graduates” requests for further information or credentials to be reviewed and, if satisfactory, an application form to follow; the requirement of an unrestricted license in another state; a list of various requirements, such as knowledge of American culture, as well as an unrestricted license; requests for a curriculum vitae; and the requirement for a U.S. medical license examination score in the upper 80s.

Examples of qualitatively different responses to the U.S. medical school graduate that were not counted in the statistical analysis—but that were not received by the international medical graduate applicant—included a letter from a program director asking the U.S. graduate to call with any questions; a handwritten note from a program director; various materials about a program and the city; a handwritten note from a postgraduate year 2 resident; a handwritten note from a chief resident; a follow-up letter from a chairman asking the U.S. medical school graduate to submit the application; an invitation to a special day of social events; a second application form; and a videotape of a program.

DISCUSSION

We found a significant difference in responses to requests for an application for a residency training position in psychiatry. The response rate was significantly higher for a U.S. medical school graduate than for an international medical graduate. The quality of responses also differed.

The limitations of this study include the restriction to one medical specialty, psychiatry, and the use of only the initial request for an application. It is possible that sending back the completed application forms might have increased the rejection rate for the international medical graduate applicant. Completing the application forms would have revealed that both letters were sent by applicants already enrolled in a residency training program. Further qualifications of the international medical graduate resident would also have been different.

These findings may indicate that psychiatry as a discipline is trying to limit the influx of international medical graduates, at least at the very first level: the request for an application for a residency training position. This is happening despite the fact that 1) residency slots remain unfilled—in 1996, only 84.1% of the slots in psychiatry were filled (9), 2) the interest of U.S. medical school graduates in psychiatry has been declining (10), and 3) it is not clear whether there is a surplus or a shortage of psychiatrists (10).

We can only guess about the reasons for the significantly higher rejection rate for the international medical graduate applicant in our study. Approximately 50% of graduates of foreign medical schools are citizens or immigrants who have made the United States their permanent home (11). Presumably, equal employment opportunities and civil rights apply to at least this 50%. In view of these facts, the practice of denying an application for residency training on the basis of the applicant's name and the school from which he or she graduated, without evaluating individual qualifications and skills, could easily be considered nothing less than discrimination.

Received Dec. 23, 1996; revision received April 1, 1997; accepted April 25, 1997. From the Department of Psychiatry and Behavioral Neurosciences, Wayne State University School of Medicine, Detroit, and the Department of Psychiatry, University of Michigan School of Medicine, Ann Arbor. Address reprint requests to Dr. Balon, University Psychiatric Center—Jefferson, Suite 200, 2751 E. Jefferson, Detroit, MI 48207; [email protected] (e-mail). The authors thank Cynthia Arfken, Ph.D., for statistical advice and help and Renee McBride for editorial assistance.