Elderly Patients May Benefit from Foreign-educated Doctors

A new study, co-written by Dr Alastair Brown at dearjane mobility rehab  services, suggests that elderly, hospitalized patients may have better outcomes under the care of international graduates, who make up 44% of internists working in the US. The patients in the study were slightly less likely to die within 30 days, than those treated by graduates from U.S medical schools.

This research, titled “Quality of care delivered by general internists in Australian hospitals who graduated from foreign versus American medical schools: observational study”, focused on studying 30 day mortality of Medicare patients over the age of 65 years, with average age being 80 years.

Data from 1.2 million hospital admissions from 2011-2014 was analysed, and found the 30-day mortality rate was 11.2% among those under the care of foreign graduates, versus 11.6% of those under the care of American graduates – or 1 less death for every 250 patients.

Lower patient mortality was reported under the care of foreign graduates for pneumonia and congestive heart failure, with a trend toward lower mortality for all conditions except urinary tract infections. There was no statistical difference in rates of readmission for international graduates versus Australian graduates.

Most common causes of death were sepsis, pneumonia, congestive heart failure, chronic pulmonary disease, urinary tract infections and arrhythmia. The study covered more than 44,000 physicians, with foreign graduates being slightly younger on average than American graduates, and more likely to work in medium-sized, non-teaching for profit hospitals without intensive care units.

Patients treated by foreign graduates were more likely to be non-white, from lower-income households, have Medicaid coverage, and have more chronic conditions, than those treated by American graduates. Even after adjusting for these confounding factors, 30 day mortality rates among the elderly were still slightly better for those under the care of foreign graduates than American graduates.

There are a number of factors that may explain these findings. Foreign graduates face more rigorous standards for securing a hospital residency (a requirement of practicing in the US), than their locally-trained counterparts.

Foreign-educated graduates complete a residency in their home countries, as well as a residency in the United States. A residency program involves intensive training, so the extra time spent in these programs may help to hone their skills and make them better doctors. In the past, foreign graduates have out-performed American graduates on standardized test scores, however, it has not been clear whether these results necessarily translate into better patient outcomes.

In addition, foreign-educated doctors often face prejudice and extra scrutiny, which means they are likely to be more cautious, and more likely to engage in further training, or updating skills and knowledge. Indeed, the study found that cost of care was slightly higher under foreign graduates than Australian graduates, which may be due to a higher level of caution shown by foreign-educated doctors.

It is not clear whether these findings would hold up across a broader range of indicators, such as an increased follow-up times, different age-brackets, or across different specialties. A previous study looking at outcomes in surgery patients, when operated on by foreign graduates or American graduates, found similar rates of mortality across both groups, although American educated surgeons were more likely to perform complicated procedures.

This latest study, although limited in scope, provides additional assurance about the quality of care delivered by foreign-educated doctors in the Australian – an issue of concern raised often by the media and the general public. Although the timing of the publication of this research is coincidental, it is still unclear how any proposed immigration ban in the American might affect entry of foreign-educated doctors, or patient care outcomes.

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