A roadmap for the twilight zone: navigating United States cardiovascular career development for international trainees.

Predictions of the demise of US preeminence in the sciences appear to have been exaggerated1; at least for now, objective measurements of the investment in and the impact of biomedical research in the United States suggest that it continues to dominate Europe, Japan, and China.2 The particular inequities of access to healthcare delivery in the United States are well documented,3,4 and objective measures of population health suggest that Americans, on average, are seriously disadvantaged, particularly compared with some Europeans.5 However, although a disproportionate investment of dollars in health care6 may not translate to universal benefit in the US system, it has created well-resourced centers of excellence that, if accessed, have the potential to deliver superior care.7 In the case of cardiology, these centers typically have well-established training programs that integrate diversified opportunities for specialized clinical training with access to mentors skilled in basic, translational, and clinical research. The comprehensive nature of these programs and their multiplicity remain unique to the United States and are sufficient reasons for every aspiring cardiologist or cardiovascular physician-scientist to consider seriously a period of training in this system. Every year, international trainees come to the United States to advance their careers in cardiovascular medicine. In 2006, international medical graduates (IMGs) from 127 countries filled 31% of accredited cardiovascular disease fellowship posts, 33% of clinical cardiac electrophysiology positions, and 46% of the interventional cardiology posts.8 In addition to clinical training, the potential for international trainees to perform cardiovascular research in the United States is considerable. Realizing the benefits of the training environment within the United States requires one to become familiar with institutional, state, and federal training requirements and with the sometimes byzantine challenges that are particular to medical graduates from countries other than the United States. This article seeks to provide international trainees with a roadmap for cardiovascular career development in the United States. Overall Trends in IMG Training and Positions in the United States The US Information and Educational Exchange Act of 1948 gave international medical school graduates the opportunity to pursue advanced medical training in the United States; since then, many have come, and many have stayed. IMGs comprise foreign national graduates of international medical schools who enter the United States on specific visa status (eg, J-1, H-1B) and US citizens and permanent residents who graduated from international medical schools. Thus, American citizens who complete their education in schools outside of the United States and Canada are classified as IMGs, and foreign nationals who complete their medical training in the United States or Canada are considered US medical graduates (USMGs). Today, 1 in 4 physicians practicing in the United States is an IMG, and IMGs occupy a third of all cardiology training posts (Figures 1 and 2).8–16 In 1959, the US Surgeon General’s consultant group on medical education published the Bane Report, which predicted a 40 000 physician deficit by the mid 1970s. In response, the number of US medical schools was increased, and by 1981 the annual number of USMGs had increased by 140%. In parallel, mechanisms were put in place to incorporate IMGs into the US physician workforce. Between 1981 and 2001, the number of USMGs and IMGs increased significantly, as did the percentage of these doctors who were IMGs (from 20.9% to 23%). IMGs were more likely to be specialists in 1981 but were more likely to be generalists by 2001. The percentage of rural patient care generalists who were IMGs increased by 45% over this period. In parallel, the percentage of hospital-based physicians who were IMGs decreased.9,17 The decline in the number of IMG specialists appears to reflect both increasing competition for specialty training positions and changing USMG career preferences. The number of specialty and subspecialty graduate medical education (GME) positions in the United States has remained relatively static since 1997, when a cap was imposed.18 Over the same period, the number of USMGs has increased, and their career preference has shifted strongly toward specialty practice and away from primary care. Thus, the general availability of