Kumar et al, in a recent issue of the Journal of Graduate Medical Education, described the perspectives of a diverse cohort of trainees on the impact of the United States Medical Licensing Examination (USMLE) pass/fail Step 1 score reporting. They found that underrepresented in medicine responders were more likely to agree that this change would decrease socioeconomic disparities, and that nearly twice as many international medical graduates (IMGs) felt they would be disadvantaged compared to US MD students.1 In addition to the USMLE scores, there are multiple challenges in the US graduate medical education (GME) journey; one of the most persuasive portions of a competitive curriculum is also among the most expensive—US clinical experience. The fee for a 4-week hands-on rotation ranges from $1,499 to $4,599,2 added to traveling expenses, which in the case of non-US IMGs includes international moving. Additionally, several programs accepting IMGs demand at least 2 months of US clinical experience to be considered a candidate, yet 8 of the top 10 nations sending physicians for Educational Commission for Foreign Medical Graduates (ECFMG) J-1 Visa Sponsorship3 have a gross national income per capita between $1,086 and $13,205.4
According to the ECFMG, the objective of the US Department of State J-1 programs is “to enhance international exchange in the field of medicine and to promote mutual understanding between the people of the United States and other countries through the interchange of persons, knowledge, and skills.”5 Residency programs that admit international physicians' applications and concurrently dismiss applicants who cannot afford US clinical experience are not aligned with this purpose. Fair judgment and selection of applicants should be based on a holistic evaluation that considers academic and professional achievements in each candidate's context. For example, high scores in standardized tests and meaningful research experience carry substantial weight when they come from someone who had to navigate through second or third language written materials, rise above heavy economic constraints, and demonstrate the willingness to run uphill in the steep curve of GME training in a completely new culture.
Residency programs rejecting IMG aspirants based on the lack of US clinical experience is a fine example of faulty inclusion of underrepresented in medicine physicians, whose limited economic status undermines the opportunity to prove themselves as valuable individuals by sharing unique backgrounds and experiences.