Effects of Citizenship Status on International Medical Graduate Specialty Choice and Practice Location.

importanceThe number of both US citizen and noncitizen international medical graduates (IMGs) practicing in the United States has grown substantially over the last two decades, but little is known about how these groups differ in clinical specialty and practice location.

objectiveTo evaluate the effects of citizenship status on IMG specialty choice (primary care vs nonprimary care) and practice location (rural and health professional shortage areas [HPSAs]).

designTo analyze the retrospective, cross sectional data between 2010 and 2019, we estimated a series of multivariate logistic regressions with year fixed effects after assessing trends in new physician specialty choice and practice location.

settingSurvey of Residents Completing Training in New York, the largest publicly available annual survey of graduating residents and fellows in the US.

participants15,133 new physicians who accepted a job offer in our study period, including 8,177 US medical graduates (USMGs), 2,753 US citizen IMGs, 1,057 permanent resident IMGs, and 3,146 noncitizen non-permanent resident (NCNP) IMGs. EXPOSURE: IMG and Citizenship status. MAIN OUTCOMES: Whether a new physician chose to practice primary care; whether a new primary care physician chose to work in a rural area; whether a new primary care physician chose to work in a HPSA.

resultsCompared to 2010, there were 20% fewer NCNP IMGs entering primary care in 2019. Our logistic analysis found that US citizen IMGs were five times, permanent resident IMGs seven times, and NCNP IMGs nine times more likely to enter primary care compared to USMGs. Among new primary care physicians, NCNP IMGs were more likely to work in a rural area compared to USMGs while US citizen IMGs and permanent resident IMGs acted similarly to USMGs. NCNP IMGs were five times more likely to work in a HPSA while US citizen IMGs and permanent resident IMGs were less likely, compared to USMGs.

conclusionThere was a declining proportion of NCNP IMGs entering primary care; citizenship status affected IMGs' specialty and practice location choices with NCNP IMGs more likely to choose primary care and work in rural areas and HPSAs.