Elderly hospitalized patients treated by doctors who graduated from non-US medical schools are slightly less likely to die within 30 days than those treated by graduates of US medical schools, according to a study published Thursday.
The study arrives amid the furor over President Trump’s 90-day ban on people from seven Muslim-majority countries entering the United States — an order that prompted concerns that it would block some foreign medical students from training and practicing here. About 1 in 4 US physicians were born abroad, and among internists, the primary care doctors who were the focus of the study, 44 percent graduated from foreign medical schools.
The journal where it was published, the BMJ, said the timing is a coincidence. The researchers launched the study a year ago and submitted it in September, and a BMJ spokeswoman said it “was always scheduled to go into next week’s print journal.” (Papers run online ahead of print.)
Dr. Ashish Jha of Harvard T.H. Chan School of Public Health and his colleagues found that 11.2 percent of Medicare patients cared for by foreign graduates died within 30 days of being admitted to a hospital, compared with 11.6 percent of those cared for by US graduates.
America “attracts the very best and the very brightest,” Jha said. “Certainly that’s true in science, and our paper says that’s true in medicine as well.” But Trump’s entry ban “sends a signal that America is not going to be as open anymore,” he added. “The ones who will lose will be American patients.”
The researchers analyzed data on 1.2 million hospital admissions of Medicare patients aged 65 and over between 2011 and 2014 and for 44,227 internists. The average age of patients was 80, and the most common causes of death were sepsis, pneumonia, congestive heart failure, and chronic obstructive pulmonary disease.
This is the first nationwide study to compare the patient outcomes of US- and foreign-educated doctors; previous research has compared test scores or adherence to quality measures. The researchers excluded from their analysis physicians who graduated from US colleges but attended medical schools in the Caribbean or Central America, which usually happens because they were not accepted by US medical schools. Those graduates “are known to be less qualified and would have biased our analysis,” said the study’s lead author, Dr. Yusuke Tsugawa, who graduated from a medical school in Japan.
One possible reason for the lower mortality among patients of foreign graduates is that requirements for winning a hospital residency, which is required to practice in the United States, are more rigorous for non-US graduates. “That might select for physicians who are, on average, more knowledgeable and skilled,” Tsugawa said. Another possible explanation is that foreign graduates have, in the past, edged US graduates on standardized test scores, though it is not clear if that’s still the case.
More likely: Most foreign graduates do two residencies, one in their home country and one in the United States, an “intensive and prolonged training” that might make them better doctors, the researchers wrote.
There’s a cultural factor, too. Because foreign doctors often face prejudice, “they might be extra cautious and ask for more consultations so as to avoid mistakes,” Tsugawa said.
A strength of the study is that nearly half the doctors were foreign medical graduates, which makes the statistics more solid than if only a small percent were, said Patrick McKnight of George Mason University, an expert in research methodology and statistics.
But a result that is statistically significant — there was less than a 0.1 percent probability that the difference the researchers found would happen by chance — might not be meaningful in real life, he cautioned. In this case, the mortality difference works out to roughly 1 fewer death per 250 patients treated by foreign-educated internists. That means 2,200 of the 66,250 deaths among the patients treated by US-educated physicians in the study might have been avoided if they were treated by foreign-educated doctors.
Whether that is a significant reduction is in the eye of the beholder: The researchers call it of “modest clinical significance,” comparable to the decline in rates of death that hospitals achieved from 2000 to 2010 by implementing quality improvements and better treatments.
Another concern is that the researchers’ focus was narrow. One could also look at one-year mortality, at younger patients, at physicians in other specialties, and many more. “Any time I see an outcome specified so narrowly I wonder what others might look like,” McKnight said. That is, it’s not clear whether the reported mortality edge for foreign-educated internists applies to other measures and other kinds of patients and doctors, too, or is an outlier.
“We don’t know whether the results will generalize,” said Michael Lavine, professor of statistics at the University of Massachusetts, Amherst.
A study last year suggests the internists’ patient outcomes are not an anomaly, however. When researchers led by Dr. Rachel Kelz of the University of Pennsylvania compared outcomes of 972,718 operations by 4,581 surgeons, they found that the rates of mortality in patients operated on by foreign medical school graduates and US graduates were almost identical: 2.1 percent and 2.2 percent, respectively. So were rates of complications: 14.3 percent vs. 14.5 percent. US-educated surgeons performed a higher number of complex procedures, however: 13.7 percent vs. 11.1 percent.
Outside experts generally praised the BMJ study for looking at many factors that differed between foreign and US graduates and might affect patient mortality: length of hospital stays, how much care patients received (a measure of how sick they were), how many chronic conditions they had, and what kind of hospitals (teaching or non-teaching) doctors worked in, among others.
The foreign graduates’ patients were more likely to be non-white, poor, covered by Medicaid, and sicker with congestive heart failure, chronic obstructive pulmonary disease, and diabetes. All of those factors increase the chance of dying and so should have given the US graduates an edge. But the mortality difference in favor of foreign-educated internists held up after accounting for the confounding factors.
The study, said Dr. Andrew Gurman, president of the American Medical Association, “provide[s] additional reassurance about the high quality of care that international medical graduates deliver in the United States.”
This story was updated on Feb. 3 with comment from the American Medical Association.