Restriction of ACGME Fellowships to Candidates Completing US and Canadian Accredited Residencies: Level of Support and Expected Consequences Emanuele Orru’, MDa,b, Ronald A. Arenson, MDc, Pamela W. Schaefer, MDd, Suresh K. Mukherji, MDe, David M. Yousem, MD, MBAa
Purpose: The aim of this study was to determine the level of support for the proposal to restrict ACGMEaccredited fellowships to candidates who completed residencies accredited by the ACGME or the Royal College of Physicians and Surgeons of Canada. Perceptions of foreign-trained international medical graduates during and after fellowships were also assessed. Methods: An e-mail survey was sent to the members of the organizations that represent academic chairpersons (the Society of Chairs of Academic Radiology Departments) and radiology residency and fellowship program directors (the Association of Program Directors in Radiology) and to the program directors of the largest American radiology subspecialty society (the American Society of Neuroradiology). Results were analyzed separately for each of the 3 societies interviewed and then as a composite report for all 3 societies. Results: Approximately 60% of the respondents said that they have offered at least one fellowship or faculty position to foreign-trained applicants in the past 5 years. More than 70% of the respondents said that these doctors performed equally to or better than American-trained ones both clinically and academically. The majority of members of all 3 societies responding opposed enactment of the rule, with the American Society of Neuroradiology being the most disapproving. The main concerns of those supporting the new rule were the inhomogeneous and sometimes unknown levels of training of the foreign-trained doctors and the need to favor American graduates. Those opposed were mostly worried about diminishing the quality of fellowship candidates, programs being unable to fill their positions, and a decrease in academic-oriented people. Conclusions: Most respondents opposed the proposed rule. The majority were supportive of foreigntrained physicians continuing their training in the United States. Key Words: Fellowship, IMG, radiology, ACGME, international J Am Coll Radiol 2014;-:---. Copyright © 2014 American College of Radiology INTRODUCTION
The ACGME accredits diagnostic radiology residencies and many of the fellowship programs in the field of radiology and its subspecialties and has done so since 1981 [1]. In late 2011, the ACGME proposed a revision to the common program requirements in subspecialty training that would restrict eligibility for a
Division of Neuroradiology, Johns Hopkins Medical Institution, Baltimore, Maryland. b University of Padua Institute of Radiology, Padua, Italy. c Department of Radiology and Biomedical Imaging, University of California, San Francisco, San Francisco, California. d Massachusetts General Hospital, Boston, Massachusetts. e Michigan State University, East Lansing, Michigan. Corresponding author and reprints: David M. Yousem, MD, MBA, Johns Hopkins Medical Institution, 600 N Wolfe Street, Phipps B100F, Baltimore, MD 21287; e-mail: [email protected]. ª 2014 American College of Radiology 1546-1440/14/$36.00 http://dx.doi.org/10.1016/j.jacr.2013.12.023
ACGME-approved positions in fellowships to candidates who have completed core residency training programs in the Unites States that are ACGME approved and Canadian programs accredited through the Royal College of Physicians and Surgeons of Canada (RCPSC). This requirement would prevent graduates of residency programs outside the United States and Canada from being eligible for ACGME-accredited fellowship positions in every subspecialty, including radiology, as of July 1, 2016. Fellowship positions can be given only to exceptional foreign-trained international medical graduates (FTIMGs) or doctors of osteopathic medicine after a careful screening process by an internal or institutional graduate medical education committee [2,3]. Therefore, the majority of FTIMGs (candidates who completed their residency training in countries other than the United States or Canada) will be prevented from 1
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routinely entering subspecialty fellowship programs without additional administrative steps, consequently limiting the options for gaining ABR certification via the 4-year alternate pathway [4]. Although FTIMGs may enter non-ACGME-approved programs, some states require ACGME-approved years of training for licensure, creating a high hurdle for independent practice. We sought to determine the levels of support for the ACGME’s proposed fellowship requirement among 3 organizations that represent academic chairpersons (the Society of Chairs of Academic Radiology Departments [SCARD]), radiology residency and fellowship program directors (the Association of Program Directors in Radiology [APDR]), and the program directors of one of the largest American radiology subspecialty societies (the American Society of Neuroradiology [ASNR]). These 3 societies were chosen in order to gather the opinions of leaders in the fields of both residency and fellowship training and directors of the largest fellowship programs in the country. We also surveyed the members of these organizations for their perceptions of the quality of work by FTIMGs during and after their fellowships, the impact the policy would have on the programs, and attitudes about the proposal and the concept of FTIMGs continuing their education in the United States. We hypothesized that the ACGME proposal would not be supported by the majority of the members of the 3 societies. We predicted that experience with FTIMGs in the past would likely lead to greater support for keeping these FTIMGs in the candidate pool for fellowships. METHODS
Our data were derived from an e-mail survey sent to the members of SCARD and the APDR and the fellowship program directors of the ASNR from April through June 2013. The survey was sent to 129 members of SCARD, 334 members of the APDR, and 90 members of the ASNR. The members of these societies were reached through a list server of members provided by the societies themselves once the survey had been approved by each society’s administrative committee and/or officers. The survey was presented by means of a Web link; to achieve a higher response rate, two reminders were sent to potential respondents on days 15 and 30. The questions were forced-choice single-option questions. Three questions allowed respondents to leave comments. There was also an open-comments section at the end of the survey. The survey was conducted using an outside vendor (SurveyMonkey.com, Palo Alto, California). Percentages of respondents were automatically generated by the surveying platform, analyzed separately for each of the 3 societies interviewed, and then analyzed as a composite report for all 3 societies. When a question included the choice “I have no experience with FTIMGs,” “I have only experience with FTIMGs,” and/or “I don’t know/no
opinion,” results were calculated only considering those respondents who had experience with both classes of graduates and who had opinions. When the question allowed an open answer, the results were grouped for trends in responses by the two reviewers in concert. Two authors reviewed the responses independently and in consensus, without individual respondent identification. Respondents were assured of confidentiality. RESULTS
The collective results from the 3 societies are reported below, whereas individual results from each society are described only if considered of particular interest to readers. The complete survey is provided in the Appendix. All results below may be accessed at the following Web site: https://it.surveymonkey.com/ analyze/?survey_id¼40766599&OPT¼NEW (user ID: JHU_Neuroradiology; password: PhippsB100). The response rates were 53.5% (69 of 129) for SCARD, 33.8% (113 of 334) for the APDR, and 66.7% (60 of 90) for the ASNR. There was no way to determine why certain individuals in societies responded whereas others did not. A survey response rate of >40% historically is considered very good (Angelo Artemakis, ASNR, personal communication). Overall, 167 of 242 respondents (69%), comprising members of all 3 societies surveyed, said that they have offered at least one fellowship position (ACGMEaccredited and non-ACGME-accredited) in their programs to FTIMGs in the past 5 years. In particular, this was stated by 60.2% of APDR respondents (68 of 113), 76.8% of SCARD respondents (53 of 69), and 76.7% of ASNR respondents (46 of 60). Similarly, 143 of 241 respondents (59.3%) stated that they have offered at least one faculty position to an FTIMG in the past 5 years. Of those respondents who have had experience with FTIMGs, 78.7% (137 of 174) believed that the foreigntrained fellows performed equally to or better than American or Canadian medical graduates (ACMGs) during their fellowships; this result included 90.2% of ASNR program directors (46 of 51) (Table 1). The same question asked to respondents who had hired FTIMGs yielded the following results: 88.3% (158 of 179) believed that the FTIMGs’ performance equaled or surpassed that of ACMGs clinically (Table 2), whereas 84.8% (151 of 178) thought the same about the FTIMGs’ teaching performance. Analysis of the data from the 3 societies studied separately showed similar results, with percentages > 70% for both questions. Question 8 dealt with the impact of this new policy on subspecialty training and allowed multiple answers. Of the 217 respondents, 38.7% (84 of 217) said that without FTIMGs, they would not be able to fill their fellowship spots, compared with 32.3% (70 of 217) who would be able to fill all their slots just with ACMGs. More than half (112 of 217) thought that there would
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Table 1. Responses to question 5: “Overall, of all the FTIMG FELLOWS you accepted that completed their residency training in a country different from the US or Canada, how would you describe their CLINICAL PERFORMANCE DURING FELLOWSHIP compared to fellows who completed residency training in the US or Canada?” Society Better Same Worse Total SCARD APDR ASNR Total
8 6 19 33
(14.5) (8.8%) (37.3%) (18.9%)
34 43 27 104
(61.8%) (63.2%) (52.9%) (59.8%)
13 19 5 75
(23.7%) (28.0%) (9.8%) (21.3%)
55 68 51 174
Note: The table includes only respondents with experience with both foreign-trained international medical graduates and American or Canadian medical graduates. APDR ¼ Association of Program Directors in Radiology; ASNR ¼ American Society of Neuroradiology; FTIMG ¼ foreign-trained international medical graduate; SCARD ¼ Society of Chairs of Academic Radiology Departments.
be less diversity, compared with 3 of 217 who thought that there would be more diversity in their programs without FTIMGs. The impact on cost was not thought to be an issue, with only 13 of 217 respondents (6%) thinking that limiting slots to ACMGs would have some kind of economic impact. Seventy-one respondents (32.7%) said that without FTIMGs, there would be fewer opportunities to establish international collaborations, compared with 1 respondent who said that there would be more. The majority (64.3% [35 of 56]) of those that responded to the two questions on the impact of this new rule on the US health care system said that not having FTIMGs as fellows would be harmful. Fiftyeight of 217 (26.7%) felt that overall, there would be no impact once the policy was enacted. Of 237 respondents, 132 (55.7%) answered that the clinical quality of their departments would not change without FTIMGs as fellows. For those who had opinions, nearly 3 times more respondents (59/20 ¼ 2.9) said that the clinical quality would get worse without FTIMGs as opposed to better. The same question about the impact on departments’ research productivity yielded even more notable results: >13 times (81/6 ¼ 13.3) more respondents said that research productivity would suffer, as opposed to improving, without FTIMG fellows. Overall, when asked about the impact of the decision on subspecialty training, more than half of the respondents who had opinions (121 of 219 [55.3%]) answered that the new policy would be harmful; 55 (25.1%) felt that the impact would be neutral, and 43 (19.6%) perceived it as favorable (Fig. 1). This was felt most strongly by program directors of the ASNR, 74.6% of whom (44 of 59) thought the new regulation to be harmful. Similarly, of those who had opinions, 141 of 240 (58.8%) opposed the implementation of the policy, 36 (15%) were neutral about it, and 63 (26.2%) supported it. Again, ASNR members were almost exclusively against the policy, with an opposition rate of 81.7% (49 of 60). APDR members showed more disparity in their
Table 2. Responses to question 6: “AFTER THEIR FELLOWSHIP, on average how would you describe the CLINICAL performance of FTIMG faculty at your institution compared to faculty who completed residency training in the US or Canada?” Society Better Same Worse Total SCARD APDR ASNR TOTAL
14 9 17 40
(24.6%) (12.5%) (34.0%) (22.4%)
36 52 30 118
(63.2%) (72.2%) (60%) (65.9%)
7 11 3 21
(12.2) (15.3%) (6.0%) (11.7%)
57 72 50 179
Note: The table includes only respondents with experience with both foreign-trained international medical graduates and American or Canadian medical graduates. APDR ¼ Association of Program Directors in Radiology; ASNR ¼ American Society of Neuroradiology; FTIMG ¼ foreign-trained international medical graduate; SCARD ¼ Society of Chairs of Academic Radiology Departments.
opinions, with 45% (50 of 111) opposing the new rule and 36.7% (41 of 111) favoring it (Fig. 2). Of those with opinions, 69.2% (144 of 208) did not favor the enactment of the new ACGME policy. The ASNR was most strongly dissatisfied with the policy, with 90.7% of responding members (49 of 54) not favoring the enactment; of APDR members, slightly more than half of the respondents (55.3% [52 of 94]) opposed enactment of the new rule. The most common open-comment remarks concerned maintaining the independence of fellowship directors in carefully selecting the individuals they think are best suited for their programs and the disparity of training standards between ACMGs and FTIMGs depending on their countries of origin. In the respondents’ opinions, many European and Australian program standards are of the same levels as American and Canadian ones. At the same time, some remarked that fellows from other countries require more tutoring by attending physicians to get to the same training level as ACMGs, and they struggle on board examinations if they choose the ABR’s alternate pathway. Remarks also addressed the value of raising the skill level of FTIMG fellows and their host countries in the developing world to the American standard of care, current and future job shortages in the United States, the negative impact of eliminating FTIMG candidates on smaller fellowship programs and the job market in underserved areas, visa and immigration problems related to hiring FTIMGs, and a negative impact on the academic output of some institutions given the perceived higher interest of FTIMGs in research and teaching. DISCUSSION
The ACGME is a private professional organization responsible for the accreditation of approximately 9,200 residency and subspecialty education programs. The objective of this organization is to improve health care by assessing and advancing the quality of resident and fellow physicians’ education through exemplary
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Fig 1. The chart shows how the 3 societies perceive the impact of the new norm on subspecialty training. The American Society of Neuroradiology (ASNR) is the society most inclined to consider the policy harmful, whereas the Association of Program Directors in Radiology (ADPR) is less worried about its effect. SCARD ¼ Society of Chairs of Academic Radiology Departments.
accreditation. The ACGME currently accredits residency programs in many different specialties, including diagnostic radiology and several of its subspecialty fellowship programs. In July 2013, the ACGME approved a final revision of the common program requirements stating that, effective July 1, 2016, ACGME-approved slots in fellowship programs will require the completion of an ACGME-accredited residency program or an RCPSCaccredited residency program located in Canada. This proposal is part of a larger project that includes the ACGME, the American Osteopathic Association, and the American Association of Colleges of Osteopathic Medicine to pursue a single, unified accreditation system for graduate medical education programs in the United States, called the Next Accreditation System [5]. Access to accredited fellowships will be allowed only to carefully selected FTIMG candidates after the positive decision of an internal review committee and a 6-week evaluation period of the fellow’s suitability for the position (provision III.A.2 b, lines 343e390). In the words of the
ACGME, this exception is not meant to be a bureaucratic shortcut to bypass the new rule but a chance for institutions to hire truly exceptional FTIMGs or doctor of osteopathic medicine candidates in a thorough screening process [3]. This exception will probably be beneficial, as it will allow exceptional candidates who do not meet the proposed eligibility criteria to join fellowship programs in the United States. The enactment of this new policy, however, will result in added hurdles for FTIMGs to obtain ACGME-accredited fellowship positions without previous completion of an ACGME-accredited or RCPSC-accredited residency program. The ACGME’s rationale for this proposal and to unify graduate medical education through a common accreditation system is stated as follows in the “impact statement” document issued by the ACGME in 2012 after the proposal [6]: The completion of prerequisite ACGME/RCPSC-accredited training promotes the quality and safety of patient care and resident training in the core specialty residency program. Fellows are expected to Fig 2. The chart shows agreement levels with the ACGME proposal. Note how the American Society of Neuroradiology (ASNR) has the highest rate of disagreement, whereas the Association of Program Directors in Radiology (ADPR) has the lowest. SCARD ¼ Society of Chairs of Academic Radiology Departments.
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supervise, advise, and instruct junior residents in the core patient care. In addition, all members of the health care team have expectations of prior levels of education and demonstrated competence based on ACGME/RCPSC-standards. These levels are unknown for non-ACGME/RCPSC educated individuals.
The ACGME thus pointed out that FTIMGs’ educational backgrounds vary greatly depending on their countries of origin and that it might not be possible to ensure that foreign applicants to subspecialty fellowships satisfy the minimum training requirements guaranteed by an ACGME-accredited or RCPSC-accredited residency program. We have collected the opinions on these new requirements for subspecialty training and on FTIMGs in the US health care system by surveying the two main radiology societies involved in trainee leadership (SCARD and the APDR) and one of the largest American radiology subspecialty societies (the ASNR). Our a priori hypothesis was that, mostly on the basis of experiences with FTIMGs in the past, the majority of members of these societies would not support this new ACGME proposal. Overall, >60% of the members of the 3 societies said that they have had experience with FTIMGs as fellows and/or faculty members and believe that these doctors performed equally to or better than ACMGs both clinically and academically. There was substantial agreement in all 3 societies that if the ACGME proposal were implemented, the level of clinical and academic expertise in their departments would more likely suffer than improve. Overall, the decision was perceived as harmful by 55% of respondents with opinions, and 69% of respondents did not favor its enactment. This negative perception was most striking in the ASNR and least so in the APDR. The reason for this may be that although the majority of fellowship programs are represented in the ADPR, the society is dominated (>90%) by residency training directors, whereas the ASNR pool represents fellowship training programs. These findings support our hypothesis that there would be general dissatisfaction with the new rule among the majority of respondents in all 3 societies. The main reasons for supporting the restrictive policy included the following: The main concern was related to the different and often unpredictable levels of training of FTIMGs. Although it was recognized that some countries have programs with quality comparable to US and Canadian ones, it was a common sentiment among those favorable to the proposal that the average level of competency of FTIMGs after their residencies is lower than that of ACMGs. This results in more effort from faculty members to bring FTIMGs to the same level as their North Americanetrained counterparts and ultimately in a loss of time from the department. Those supporting the policy felt that although
some FTIMGs perform excellently, the majority have poorer skills compared with ACMGs. Some respondents proposed that the ACGME recognize some overseas residency programs (mainly in Western Europe and Australia) as being of the same level as the ACGME-accredited ones, thus eliminating the proposed requisites for FTIMGs from those countries. Considering a potential job shortage in radiology and the increase in the number of graduates from US and Canadian medical schools, some respondents thought that it would make no sense to leave some North American graduates without employment in their subspecialty fields of choice in favor of FTIMGs who have obtained most of their training overseas. Because of immigration requirements (visas, sponsorships, and medical insurance), some respondents felt that hiring an FTIMG would result in higher employment costs or added administrative time. Because the concept of the alternate pathway is exclusive to radiology, some interviewees felt that it would be fairer to have a single system for all medical specialties. Those opposed to the new ACGME policy expressed the following opinions: The responsibility of hiring physicians in subspecialty fellowships should ultimately remain with the fellowship director. In the opinion of many respondents, it is most beneficial to a department if each director carefully chooses his or her candidates, regardless of the countries where they obtained their training: “may the best man or woman win.” It is perceived that FTIMGs have more interest in academics than ACMGs; the rule might be harmful to teaching institutions that would have difficulty hiring faculty members from a pool of ACMGs, who would preferentially select private practice positions. Many departments throughout the United States and Canada have hired physicians trained overseas who became certified through the alternate pathway and became productive faculty members and even program directors. Thus, the rule may prevent American departments from hiring highly talented and motivated physicians because of state requirements for ACGME-accredited years of training. Some programs, especially those in smaller cities and in mostly rural areas, rely heavily on FTIMGs to fill all of their positions. Directors of these programs feared that they would not be able to fill their programs or that the existence of the programs themselves would be endangered by the enactment of the rule. Other respondents stated that the rule might result in less diversity and international collaborations and that it is fundamentally “against” the principles of advancing medicine’s globalization. The benefit of US-trained foreign physicians’ returning home to their countries
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of origin after the completion of their fellowships was also raised, particularly in those countries that do not offer fellowship training in radiology subspecialties. Of medical societies proffering opinions, the most notable has been the Alliance for Academic Internal Medicine. Represented by its president, D. Craig Brater, MD, the society sent an open letter to the ACGME in November 2011 stating that internal medicine trainees have adequate oversight and training regardless of their backgrounds. Also noted was that some subspecialties would have difficulty filling their positions without physicians coming from nonaccredited residency programs. Comments from societies representing different subspecialties of medicine raise similar concerns [7]. This study had some limitations. First, because the survey was anonymized, there is no way to measure differences among respondents (rural vs urban areas, different program sizes). Second, there might be an overlap between respondents if they are members of more than one society at the same time. However, it is unlikely that a respondent filled in the survey twice given the imposition on the respondent’s time. Third, some respondents might belong to the same institution, such as the chair (SCARD), residency training director (the APDR), and neuroradiology fellowship director (the ASNR). However these individuals may have differing opinions on the policy as opposed to a unified “institutional” opinion. Fourth, some respondents openly stated that their programs rely on FTIMGs to fill all their positions; their answers might thus be biased by this conflict of interest. Fifth, the opinions of the program directors in neuroradiology, sought to represent subspecialty program directors in general (along with APDR input), might not reflect all radiology subspecialties’ attitudes on the issue. Finally, the studied population is constituted by academic radiologists, so the opinions of members of the nonacademic radiology world are not represented. TAKE-HOME POINTS
More than half of the members of the 3 societies interviewed do not agree with the policy preventing
FTIMGs from joining ACGME-accredited fellowship programs. The majority of the respondents believe that this policy will not be beneficial to the field of radiology. The main reasons in support of a restrictive policy were the different levels of training of FTIMGs compared with ACMGs, immigration-related costs and added bureaucracy, and the need to protect ACMGs in a period of job shortage in the United States. The main reasons for opposition to the ACGME restrictions were the perceived higher interest of FTIMGs in academic medicine and research, the high quality of the applicants, the desire to train people who can bring high-quality fellowship-trained radiology experience back to their home countries, and the need for international medical graduate applicants to fill otherwise vacant positions. REFERENCES 1. Accreditation Council for Graduate Medical Education. ACGME history. Available at: http://www.acgme.org/acgmeweb/tabid/122/About/ ACGMEHistory.aspx. Accessed October 19, 2013. 2. American Osteopathic Association. Timeline: AOA response to ACGME changes. Available at: http://www.osteopathic.org/inside-aoa/Pages/ acgme-policy-timeline.aspx. Accessed November 21, 2013. 3. Accreditation Council for Graduate Medical Education. ACGME common program requirements. Available at: http://www.acgme.org/ acgmeweb/Portals/0/PDFs/CPR_Eligibility.pdf. Accessed October 10, 2013. 4. American Board of Radiology. Policy for alternate pathways to certification in diagnostic radiology and subspecialty certification for international medical graduates. Available at: http://www.theabr.org/the_abr/sites/all/ themes/abr-media/pdf/img_policy.pdf. Accessed November 18, 2013. 5. Accreditation Council for Graduate Medical Education. The Next Accreditation System. Available at: http://www.acgme-nas.org. Accessed November 21, 2013. 6. Accreditation Council for Graduate Medical Education. ACGME common program requirements for graduate medical education: summary and impact of proposed revisions. Available at: http://www.acgme.org/ acgmeweb/Portals/0/PDFs/CPR_Impact.pdf. Accessed on November 21, 2013. 7. Alliance for Academic Internal Medicine. Letter to Jerry Vasilias, MD, executive director, Residency Review Committee for Internal Medicine, ACGME. Available at: http://www.im.org/AcademicAffairs/Accreditation/ Documents/11-11-22_AAIM%20Comments_ACGME%20Common%20 Program%20Requirements.pdf. Accessed November 21, 2013.
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APPENDIX
1. In the past 5 years have you offered fellowship positions (ACGME and non ACGME accredited positions) in your program to candidates who completed their residency training in a country different from the US or Canada? ( ) Yes ( ) No 2. If yes, how many in the past 5 years? ()1 ( ) 2-3 ( ) 4-5 ( ) 6-8 ( ) >8 3. In the past 5 years have you offered a faculty/staff position to a board certified/eligible IMG who has completed a fellowship in a North American institution but has had his/her residency training in a country different from the US or Canada? ( ) Yes ( ) No 4. If yes, how many in the past 5 years? ()1 ( ) 2-3 ( ) 4-5 ( ) 6-8 ( ) >8 5. Overall, of all the IMG FELLOWS you accepted that completed their residency training in a country different from the US or Canada, how would you describe their CLINICAL PERFORMANCE DURING FELLOWSHIP compared to fellows who completed residency training in the US or Canada? ( ) Worse ( ) Same ( ) Better ( ) I have had no experience with IMGs ( ) I only have experience with IMGs 6. AFTER THEIR FELLOWSHIP, on average how would you describe the CLINICAL performance of IMG faculty at your institution compared to faculty who completed residency training in the US or Canada? ( ) Worse ( ) Same ( ) Better ( ) I have had no experience with IMGs ( ) I only have experience with IMGs
7. AFTER THEIR FELLOWSHIP, on average how would you describe the TEACHING performance of IMG faculty at your institution compared to faculty who completed residency training in the US or Canada? ( ) Worse ( ) Same ( ) Better ( ) I have had no experience with IMGs ( ) I only have experience with IMGs 8. In what way would your fellowship program be different without IMG graduates? (Choose all that apply) ( ) We would likely not be able to fill our fellowship positions ( ) We would be able to fill our positions just with fellows who completed US/Canadian residency training ( ) We would have less diversity in our program ( ) We would have more diversity in our program ( ) There would be no impact ( ) It would cost us more to run our fellowship program ( ) It would cost us less to run our program ( ) There would be less opportunity to make international collaborations ( ) There would be more opportunity to make international collaborations ( ) We would benefit our domestic healthcare system ( ) We would harm our domestic healthcare system 9. Overall, what would be the impact on the CLINICAL quality of your department without IMG fellows? ( ) Get better ( ) Get worse ( ) I don’t know / no opinion ( ) No change 10. Overall, what would be the impact on the RESEARCH PRODUCTIVITY of your department without IMG fellows? ( ) Get better ( ) Get worse ( ) I don’t know / no opinion ( ) No change 11. Overall, I think that the impact of this decision on SUBSPECIALTY TRAINING will be: ( ) Favorable ( ) Neutral ( ) Harmful ( ) I don’t know / no opinion 12. How do you feel about the policy to limit radiology ACGME accredited fellowship positions (and to
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consequentially limit future ABR board eligibility) only to candidates who completed residency training in US/Canada? ( ) Strongly disagree ( ) Disagree ( ) Neutral ( ) Agree ( ) Strongly agree 13. Do you think that this decision will discourage IMGs from applying to clinical or research fellowship training in the US?
( ( ( ( (
) ) ) ) )
Yes, both Yes, only clinical Yes, only research No I don’t know / no opinion
14. Would you like this policy, restricting ACGME radiology fellowships to candidates who have completed US/Canadian residency programs, to be enacted? ( ) Yes ( ) No ( ) I don’t know / no opinion
Purpose: The aim of this study was to determine the level of support for the proposal to restrict ACGMEaccredited fellowships to candidates who completed residencies accredited by the ACGME or the Royal College of Physicians and Surgeons of Canada. Perceptions of foreign-trained international medical graduates during and after fellowships were also assessed. Methods: An e-mail survey was sent to the members of the organizations that represent academic chairpersons (the Society of Chairs of Academic Radiology Departments) and radiology residency and fellowship program directors (the Association of Program Directors in Radiology) and to the program directors of the largest American radiology subspecialty society (the American Society of Neuroradiology). Results were analyzed separately for each of the 3 societies interviewed and then as a composite report for all 3 societies. Results: Approximately 60% of the respondents said that they have offered at least one fellowship or faculty position to foreign-trained applicants in the past 5 years. More than 70% of the respondents said that these doctors performed equally to or better than American-trained ones both clinically and academically. The majority of members of all 3 societies responding opposed enactment of the rule, with the American Society of Neuroradiology being the most disapproving. The main concerns of those supporting the new rule were the inhomogeneous and sometimes unknown levels of training of the foreign-trained doctors and the need to favor American graduates. Those opposed were mostly worried about diminishing the quality of fellowship candidates, programs being unable to fill their positions, and a decrease in academic-oriented people. Conclusions: Most respondents opposed the proposed rule. The majority were supportive of foreigntrained physicians continuing their training in the United States. Key Words: Fellowship, IMG, radiology, ACGME, international J Am Coll Radiol 2014;-:---. Copyright © 2014 American College of Radiology INTRODUCTION
The ACGME accredits diagnostic radiology residencies and many of the fellowship programs in the field of radiology and its subspecialties and has done so since 1981 [1]. In late 2011, the ACGME proposed a revision to the common program requirements in subspecialty training that would restrict eligibility for a
Division of Neuroradiology, Johns Hopkins Medical Institution, Baltimore, Maryland. b University of Padua Institute of Radiology, Padua, Italy. c Department of Radiology and Biomedical Imaging, University of California, San Francisco, San Francisco, California. d Massachusetts General Hospital, Boston, Massachusetts. e Michigan State University, East Lansing, Michigan. Corresponding author and reprints: David M. Yousem, MD, MBA, Johns Hopkins Medical Institution, 600 N Wolfe Street, Phipps B100F, Baltimore, MD 21287; e-mail: [email protected]. ª 2014 American College of Radiology 1546-1440/14/$36.00 http://dx.doi.org/10.1016/j.jacr.2013.12.023
ACGME-approved positions in fellowships to candidates who have completed core residency training programs in the Unites States that are ACGME approved and Canadian programs accredited through the Royal College of Physicians and Surgeons of Canada (RCPSC). This requirement would prevent graduates of residency programs outside the United States and Canada from being eligible for ACGME-accredited fellowship positions in every subspecialty, including radiology, as of July 1, 2016. Fellowship positions can be given only to exceptional foreign-trained international medical graduates (FTIMGs) or doctors of osteopathic medicine after a careful screening process by an internal or institutional graduate medical education committee [2,3]. Therefore, the majority of FTIMGs (candidates who completed their residency training in countries other than the United States or Canada) will be prevented from 1
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routinely entering subspecialty fellowship programs without additional administrative steps, consequently limiting the options for gaining ABR certification via the 4-year alternate pathway [4]. Although FTIMGs may enter non-ACGME-approved programs, some states require ACGME-approved years of training for licensure, creating a high hurdle for independent practice. We sought to determine the levels of support for the ACGME’s proposed fellowship requirement among 3 organizations that represent academic chairpersons (the Society of Chairs of Academic Radiology Departments [SCARD]), radiology residency and fellowship program directors (the Association of Program Directors in Radiology [APDR]), and the program directors of one of the largest American radiology subspecialty societies (the American Society of Neuroradiology [ASNR]). These 3 societies were chosen in order to gather the opinions of leaders in the fields of both residency and fellowship training and directors of the largest fellowship programs in the country. We also surveyed the members of these organizations for their perceptions of the quality of work by FTIMGs during and after their fellowships, the impact the policy would have on the programs, and attitudes about the proposal and the concept of FTIMGs continuing their education in the United States. We hypothesized that the ACGME proposal would not be supported by the majority of the members of the 3 societies. We predicted that experience with FTIMGs in the past would likely lead to greater support for keeping these FTIMGs in the candidate pool for fellowships. METHODS
Our data were derived from an e-mail survey sent to the members of SCARD and the APDR and the fellowship program directors of the ASNR from April through June 2013. The survey was sent to 129 members of SCARD, 334 members of the APDR, and 90 members of the ASNR. The members of these societies were reached through a list server of members provided by the societies themselves once the survey had been approved by each society’s administrative committee and/or officers. The survey was presented by means of a Web link; to achieve a higher response rate, two reminders were sent to potential respondents on days 15 and 30. The questions were forced-choice single-option questions. Three questions allowed respondents to leave comments. There was also an open-comments section at the end of the survey. The survey was conducted using an outside vendor (SurveyMonkey.com, Palo Alto, California). Percentages of respondents were automatically generated by the surveying platform, analyzed separately for each of the 3 societies interviewed, and then analyzed as a composite report for all 3 societies. When a question included the choice “I have no experience with FTIMGs,” “I have only experience with FTIMGs,” and/or “I don’t know/no
opinion,” results were calculated only considering those respondents who had experience with both classes of graduates and who had opinions. When the question allowed an open answer, the results were grouped for trends in responses by the two reviewers in concert. Two authors reviewed the responses independently and in consensus, without individual respondent identification. Respondents were assured of confidentiality. RESULTS
The collective results from the 3 societies are reported below, whereas individual results from each society are described only if considered of particular interest to readers. The complete survey is provided in the Appendix. All results below may be accessed at the following Web site: https://it.surveymonkey.com/ analyze/?survey_id¼40766599&OPT¼NEW (user ID: JHU_Neuroradiology; password: PhippsB100). The response rates were 53.5% (69 of 129) for SCARD, 33.8% (113 of 334) for the APDR, and 66.7% (60 of 90) for the ASNR. There was no way to determine why certain individuals in societies responded whereas others did not. A survey response rate of >40% historically is considered very good (Angelo Artemakis, ASNR, personal communication). Overall, 167 of 242 respondents (69%), comprising members of all 3 societies surveyed, said that they have offered at least one fellowship position (ACGMEaccredited and non-ACGME-accredited) in their programs to FTIMGs in the past 5 years. In particular, this was stated by 60.2% of APDR respondents (68 of 113), 76.8% of SCARD respondents (53 of 69), and 76.7% of ASNR respondents (46 of 60). Similarly, 143 of 241 respondents (59.3%) stated that they have offered at least one faculty position to an FTIMG in the past 5 years. Of those respondents who have had experience with FTIMGs, 78.7% (137 of 174) believed that the foreigntrained fellows performed equally to or better than American or Canadian medical graduates (ACMGs) during their fellowships; this result included 90.2% of ASNR program directors (46 of 51) (Table 1). The same question asked to respondents who had hired FTIMGs yielded the following results: 88.3% (158 of 179) believed that the FTIMGs’ performance equaled or surpassed that of ACMGs clinically (Table 2), whereas 84.8% (151 of 178) thought the same about the FTIMGs’ teaching performance. Analysis of the data from the 3 societies studied separately showed similar results, with percentages > 70% for both questions. Question 8 dealt with the impact of this new policy on subspecialty training and allowed multiple answers. Of the 217 respondents, 38.7% (84 of 217) said that without FTIMGs, they would not be able to fill their fellowship spots, compared with 32.3% (70 of 217) who would be able to fill all their slots just with ACMGs. More than half (112 of 217) thought that there would
Orru’ et al/Restriction of ACGME Fellowships 3
Table 1. Responses to question 5: “Overall, of all the FTIMG FELLOWS you accepted that completed their residency training in a country different from the US or Canada, how would you describe their CLINICAL PERFORMANCE DURING FELLOWSHIP compared to fellows who completed residency training in the US or Canada?” Society Better Same Worse Total SCARD APDR ASNR Total
8 6 19 33
(14.5) (8.8%) (37.3%) (18.9%)
34 43 27 104
(61.8%) (63.2%) (52.9%) (59.8%)
13 19 5 75
(23.7%) (28.0%) (9.8%) (21.3%)
55 68 51 174
Note: The table includes only respondents with experience with both foreign-trained international medical graduates and American or Canadian medical graduates. APDR ¼ Association of Program Directors in Radiology; ASNR ¼ American Society of Neuroradiology; FTIMG ¼ foreign-trained international medical graduate; SCARD ¼ Society of Chairs of Academic Radiology Departments.
be less diversity, compared with 3 of 217 who thought that there would be more diversity in their programs without FTIMGs. The impact on cost was not thought to be an issue, with only 13 of 217 respondents (6%) thinking that limiting slots to ACMGs would have some kind of economic impact. Seventy-one respondents (32.7%) said that without FTIMGs, there would be fewer opportunities to establish international collaborations, compared with 1 respondent who said that there would be more. The majority (64.3% [35 of 56]) of those that responded to the two questions on the impact of this new rule on the US health care system said that not having FTIMGs as fellows would be harmful. Fiftyeight of 217 (26.7%) felt that overall, there would be no impact once the policy was enacted. Of 237 respondents, 132 (55.7%) answered that the clinical quality of their departments would not change without FTIMGs as fellows. For those who had opinions, nearly 3 times more respondents (59/20 ¼ 2.9) said that the clinical quality would get worse without FTIMGs as opposed to better. The same question about the impact on departments’ research productivity yielded even more notable results: >13 times (81/6 ¼ 13.3) more respondents said that research productivity would suffer, as opposed to improving, without FTIMG fellows. Overall, when asked about the impact of the decision on subspecialty training, more than half of the respondents who had opinions (121 of 219 [55.3%]) answered that the new policy would be harmful; 55 (25.1%) felt that the impact would be neutral, and 43 (19.6%) perceived it as favorable (Fig. 1). This was felt most strongly by program directors of the ASNR, 74.6% of whom (44 of 59) thought the new regulation to be harmful. Similarly, of those who had opinions, 141 of 240 (58.8%) opposed the implementation of the policy, 36 (15%) were neutral about it, and 63 (26.2%) supported it. Again, ASNR members were almost exclusively against the policy, with an opposition rate of 81.7% (49 of 60). APDR members showed more disparity in their
Table 2. Responses to question 6: “AFTER THEIR FELLOWSHIP, on average how would you describe the CLINICAL performance of FTIMG faculty at your institution compared to faculty who completed residency training in the US or Canada?” Society Better Same Worse Total SCARD APDR ASNR TOTAL
14 9 17 40
(24.6%) (12.5%) (34.0%) (22.4%)
36 52 30 118
(63.2%) (72.2%) (60%) (65.9%)
7 11 3 21
(12.2) (15.3%) (6.0%) (11.7%)
57 72 50 179
Note: The table includes only respondents with experience with both foreign-trained international medical graduates and American or Canadian medical graduates. APDR ¼ Association of Program Directors in Radiology; ASNR ¼ American Society of Neuroradiology; FTIMG ¼ foreign-trained international medical graduate; SCARD ¼ Society of Chairs of Academic Radiology Departments.
opinions, with 45% (50 of 111) opposing the new rule and 36.7% (41 of 111) favoring it (Fig. 2). Of those with opinions, 69.2% (144 of 208) did not favor the enactment of the new ACGME policy. The ASNR was most strongly dissatisfied with the policy, with 90.7% of responding members (49 of 54) not favoring the enactment; of APDR members, slightly more than half of the respondents (55.3% [52 of 94]) opposed enactment of the new rule. The most common open-comment remarks concerned maintaining the independence of fellowship directors in carefully selecting the individuals they think are best suited for their programs and the disparity of training standards between ACMGs and FTIMGs depending on their countries of origin. In the respondents’ opinions, many European and Australian program standards are of the same levels as American and Canadian ones. At the same time, some remarked that fellows from other countries require more tutoring by attending physicians to get to the same training level as ACMGs, and they struggle on board examinations if they choose the ABR’s alternate pathway. Remarks also addressed the value of raising the skill level of FTIMG fellows and their host countries in the developing world to the American standard of care, current and future job shortages in the United States, the negative impact of eliminating FTIMG candidates on smaller fellowship programs and the job market in underserved areas, visa and immigration problems related to hiring FTIMGs, and a negative impact on the academic output of some institutions given the perceived higher interest of FTIMGs in research and teaching. DISCUSSION
The ACGME is a private professional organization responsible for the accreditation of approximately 9,200 residency and subspecialty education programs. The objective of this organization is to improve health care by assessing and advancing the quality of resident and fellow physicians’ education through exemplary
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Fig 1. The chart shows how the 3 societies perceive the impact of the new norm on subspecialty training. The American Society of Neuroradiology (ASNR) is the society most inclined to consider the policy harmful, whereas the Association of Program Directors in Radiology (ADPR) is less worried about its effect. SCARD ¼ Society of Chairs of Academic Radiology Departments.
accreditation. The ACGME currently accredits residency programs in many different specialties, including diagnostic radiology and several of its subspecialty fellowship programs. In July 2013, the ACGME approved a final revision of the common program requirements stating that, effective July 1, 2016, ACGME-approved slots in fellowship programs will require the completion of an ACGME-accredited residency program or an RCPSCaccredited residency program located in Canada. This proposal is part of a larger project that includes the ACGME, the American Osteopathic Association, and the American Association of Colleges of Osteopathic Medicine to pursue a single, unified accreditation system for graduate medical education programs in the United States, called the Next Accreditation System [5]. Access to accredited fellowships will be allowed only to carefully selected FTIMG candidates after the positive decision of an internal review committee and a 6-week evaluation period of the fellow’s suitability for the position (provision III.A.2 b, lines 343e390). In the words of the
ACGME, this exception is not meant to be a bureaucratic shortcut to bypass the new rule but a chance for institutions to hire truly exceptional FTIMGs or doctor of osteopathic medicine candidates in a thorough screening process [3]. This exception will probably be beneficial, as it will allow exceptional candidates who do not meet the proposed eligibility criteria to join fellowship programs in the United States. The enactment of this new policy, however, will result in added hurdles for FTIMGs to obtain ACGME-accredited fellowship positions without previous completion of an ACGME-accredited or RCPSC-accredited residency program. The ACGME’s rationale for this proposal and to unify graduate medical education through a common accreditation system is stated as follows in the “impact statement” document issued by the ACGME in 2012 after the proposal [6]: The completion of prerequisite ACGME/RCPSC-accredited training promotes the quality and safety of patient care and resident training in the core specialty residency program. Fellows are expected to Fig 2. The chart shows agreement levels with the ACGME proposal. Note how the American Society of Neuroradiology (ASNR) has the highest rate of disagreement, whereas the Association of Program Directors in Radiology (ADPR) has the lowest. SCARD ¼ Society of Chairs of Academic Radiology Departments.
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supervise, advise, and instruct junior residents in the core patient care. In addition, all members of the health care team have expectations of prior levels of education and demonstrated competence based on ACGME/RCPSC-standards. These levels are unknown for non-ACGME/RCPSC educated individuals.
The ACGME thus pointed out that FTIMGs’ educational backgrounds vary greatly depending on their countries of origin and that it might not be possible to ensure that foreign applicants to subspecialty fellowships satisfy the minimum training requirements guaranteed by an ACGME-accredited or RCPSC-accredited residency program. We have collected the opinions on these new requirements for subspecialty training and on FTIMGs in the US health care system by surveying the two main radiology societies involved in trainee leadership (SCARD and the APDR) and one of the largest American radiology subspecialty societies (the ASNR). Our a priori hypothesis was that, mostly on the basis of experiences with FTIMGs in the past, the majority of members of these societies would not support this new ACGME proposal. Overall, >60% of the members of the 3 societies said that they have had experience with FTIMGs as fellows and/or faculty members and believe that these doctors performed equally to or better than ACMGs both clinically and academically. There was substantial agreement in all 3 societies that if the ACGME proposal were implemented, the level of clinical and academic expertise in their departments would more likely suffer than improve. Overall, the decision was perceived as harmful by 55% of respondents with opinions, and 69% of respondents did not favor its enactment. This negative perception was most striking in the ASNR and least so in the APDR. The reason for this may be that although the majority of fellowship programs are represented in the ADPR, the society is dominated (>90%) by residency training directors, whereas the ASNR pool represents fellowship training programs. These findings support our hypothesis that there would be general dissatisfaction with the new rule among the majority of respondents in all 3 societies. The main reasons for supporting the restrictive policy included the following: The main concern was related to the different and often unpredictable levels of training of FTIMGs. Although it was recognized that some countries have programs with quality comparable to US and Canadian ones, it was a common sentiment among those favorable to the proposal that the average level of competency of FTIMGs after their residencies is lower than that of ACMGs. This results in more effort from faculty members to bring FTIMGs to the same level as their North Americanetrained counterparts and ultimately in a loss of time from the department. Those supporting the policy felt that although
some FTIMGs perform excellently, the majority have poorer skills compared with ACMGs. Some respondents proposed that the ACGME recognize some overseas residency programs (mainly in Western Europe and Australia) as being of the same level as the ACGME-accredited ones, thus eliminating the proposed requisites for FTIMGs from those countries. Considering a potential job shortage in radiology and the increase in the number of graduates from US and Canadian medical schools, some respondents thought that it would make no sense to leave some North American graduates without employment in their subspecialty fields of choice in favor of FTIMGs who have obtained most of their training overseas. Because of immigration requirements (visas, sponsorships, and medical insurance), some respondents felt that hiring an FTIMG would result in higher employment costs or added administrative time. Because the concept of the alternate pathway is exclusive to radiology, some interviewees felt that it would be fairer to have a single system for all medical specialties. Those opposed to the new ACGME policy expressed the following opinions: The responsibility of hiring physicians in subspecialty fellowships should ultimately remain with the fellowship director. In the opinion of many respondents, it is most beneficial to a department if each director carefully chooses his or her candidates, regardless of the countries where they obtained their training: “may the best man or woman win.” It is perceived that FTIMGs have more interest in academics than ACMGs; the rule might be harmful to teaching institutions that would have difficulty hiring faculty members from a pool of ACMGs, who would preferentially select private practice positions. Many departments throughout the United States and Canada have hired physicians trained overseas who became certified through the alternate pathway and became productive faculty members and even program directors. Thus, the rule may prevent American departments from hiring highly talented and motivated physicians because of state requirements for ACGME-accredited years of training. Some programs, especially those in smaller cities and in mostly rural areas, rely heavily on FTIMGs to fill all of their positions. Directors of these programs feared that they would not be able to fill their programs or that the existence of the programs themselves would be endangered by the enactment of the rule. Other respondents stated that the rule might result in less diversity and international collaborations and that it is fundamentally “against” the principles of advancing medicine’s globalization. The benefit of US-trained foreign physicians’ returning home to their countries
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of origin after the completion of their fellowships was also raised, particularly in those countries that do not offer fellowship training in radiology subspecialties. Of medical societies proffering opinions, the most notable has been the Alliance for Academic Internal Medicine. Represented by its president, D. Craig Brater, MD, the society sent an open letter to the ACGME in November 2011 stating that internal medicine trainees have adequate oversight and training regardless of their backgrounds. Also noted was that some subspecialties would have difficulty filling their positions without physicians coming from nonaccredited residency programs. Comments from societies representing different subspecialties of medicine raise similar concerns [7]. This study had some limitations. First, because the survey was anonymized, there is no way to measure differences among respondents (rural vs urban areas, different program sizes). Second, there might be an overlap between respondents if they are members of more than one society at the same time. However, it is unlikely that a respondent filled in the survey twice given the imposition on the respondent’s time. Third, some respondents might belong to the same institution, such as the chair (SCARD), residency training director (the APDR), and neuroradiology fellowship director (the ASNR). However these individuals may have differing opinions on the policy as opposed to a unified “institutional” opinion. Fourth, some respondents openly stated that their programs rely on FTIMGs to fill all their positions; their answers might thus be biased by this conflict of interest. Fifth, the opinions of the program directors in neuroradiology, sought to represent subspecialty program directors in general (along with APDR input), might not reflect all radiology subspecialties’ attitudes on the issue. Finally, the studied population is constituted by academic radiologists, so the opinions of members of the nonacademic radiology world are not represented. TAKE-HOME POINTS
More than half of the members of the 3 societies interviewed do not agree with the policy preventing
FTIMGs from joining ACGME-accredited fellowship programs. The majority of the respondents believe that this policy will not be beneficial to the field of radiology. The main reasons in support of a restrictive policy were the different levels of training of FTIMGs compared with ACMGs, immigration-related costs and added bureaucracy, and the need to protect ACMGs in a period of job shortage in the United States. The main reasons for opposition to the ACGME restrictions were the perceived higher interest of FTIMGs in academic medicine and research, the high quality of the applicants, the desire to train people who can bring high-quality fellowship-trained radiology experience back to their home countries, and the need for international medical graduate applicants to fill otherwise vacant positions. REFERENCES 1. Accreditation Council for Graduate Medical Education. ACGME history. Available at: http://www.acgme.org/acgmeweb/tabid/122/About/ ACGMEHistory.aspx. Accessed October 19, 2013. 2. American Osteopathic Association. Timeline: AOA response to ACGME changes. Available at: http://www.osteopathic.org/inside-aoa/Pages/ acgme-policy-timeline.aspx. Accessed November 21, 2013. 3. Accreditation Council for Graduate Medical Education. ACGME common program requirements. Available at: http://www.acgme.org/ acgmeweb/Portals/0/PDFs/CPR_Eligibility.pdf. Accessed October 10, 2013. 4. American Board of Radiology. Policy for alternate pathways to certification in diagnostic radiology and subspecialty certification for international medical graduates. Available at: http://www.theabr.org/the_abr/sites/all/ themes/abr-media/pdf/img_policy.pdf. Accessed November 18, 2013. 5. Accreditation Council for Graduate Medical Education. The Next Accreditation System. Available at: http://www.acgme-nas.org. Accessed November 21, 2013. 6. Accreditation Council for Graduate Medical Education. ACGME common program requirements for graduate medical education: summary and impact of proposed revisions. Available at: http://www.acgme.org/ acgmeweb/Portals/0/PDFs/CPR_Impact.pdf. Accessed on November 21, 2013. 7. Alliance for Academic Internal Medicine. Letter to Jerry Vasilias, MD, executive director, Residency Review Committee for Internal Medicine, ACGME. Available at: http://www.im.org/AcademicAffairs/Accreditation/ Documents/11-11-22_AAIM%20Comments_ACGME%20Common%20 Program%20Requirements.pdf. Accessed November 21, 2013.
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APPENDIX
1. In the past 5 years have you offered fellowship positions (ACGME and non ACGME accredited positions) in your program to candidates who completed their residency training in a country different from the US or Canada? ( ) Yes ( ) No 2. If yes, how many in the past 5 years? ()1 ( ) 2-3 ( ) 4-5 ( ) 6-8 ( ) >8 3. In the past 5 years have you offered a faculty/staff position to a board certified/eligible IMG who has completed a fellowship in a North American institution but has had his/her residency training in a country different from the US or Canada? ( ) Yes ( ) No 4. If yes, how many in the past 5 years? ()1 ( ) 2-3 ( ) 4-5 ( ) 6-8 ( ) >8 5. Overall, of all the IMG FELLOWS you accepted that completed their residency training in a country different from the US or Canada, how would you describe their CLINICAL PERFORMANCE DURING FELLOWSHIP compared to fellows who completed residency training in the US or Canada? ( ) Worse ( ) Same ( ) Better ( ) I have had no experience with IMGs ( ) I only have experience with IMGs 6. AFTER THEIR FELLOWSHIP, on average how would you describe the CLINICAL performance of IMG faculty at your institution compared to faculty who completed residency training in the US or Canada? ( ) Worse ( ) Same ( ) Better ( ) I have had no experience with IMGs ( ) I only have experience with IMGs
7. AFTER THEIR FELLOWSHIP, on average how would you describe the TEACHING performance of IMG faculty at your institution compared to faculty who completed residency training in the US or Canada? ( ) Worse ( ) Same ( ) Better ( ) I have had no experience with IMGs ( ) I only have experience with IMGs 8. In what way would your fellowship program be different without IMG graduates? (Choose all that apply) ( ) We would likely not be able to fill our fellowship positions ( ) We would be able to fill our positions just with fellows who completed US/Canadian residency training ( ) We would have less diversity in our program ( ) We would have more diversity in our program ( ) There would be no impact ( ) It would cost us more to run our fellowship program ( ) It would cost us less to run our program ( ) There would be less opportunity to make international collaborations ( ) There would be more opportunity to make international collaborations ( ) We would benefit our domestic healthcare system ( ) We would harm our domestic healthcare system 9. Overall, what would be the impact on the CLINICAL quality of your department without IMG fellows? ( ) Get better ( ) Get worse ( ) I don’t know / no opinion ( ) No change 10. Overall, what would be the impact on the RESEARCH PRODUCTIVITY of your department without IMG fellows? ( ) Get better ( ) Get worse ( ) I don’t know / no opinion ( ) No change 11. Overall, I think that the impact of this decision on SUBSPECIALTY TRAINING will be: ( ) Favorable ( ) Neutral ( ) Harmful ( ) I don’t know / no opinion 12. How do you feel about the policy to limit radiology ACGME accredited fellowship positions (and to
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consequentially limit future ABR board eligibility) only to candidates who completed residency training in US/Canada? ( ) Strongly disagree ( ) Disagree ( ) Neutral ( ) Agree ( ) Strongly agree 13. Do you think that this decision will discourage IMGs from applying to clinical or research fellowship training in the US?
( ( ( ( (
) ) ) ) )
Yes, both Yes, only clinical Yes, only research No I don’t know / no opinion
14. Would you like this policy, restricting ACGME radiology fellowships to candidates who have completed US/Canadian residency programs, to be enacted? ( ) Yes ( ) No ( ) I don’t know / no opinion
