This document proposes an International Medical Graduate (IMG) training program in Onondaga County, New York to address several problems: health and socioeconomic disparities in underserved communities, unemployment of over 90 local IMGs, and a shortage of physicians, especially minority physicians. The program would provide intensive English training, clinical shadowing, electronic health records training, and MCAT preparation to IMGs to help them enter residency programs and practice in underserved communities. Modeled after a program at UCLA, it has the potential to improve healthcare access and reduce costs through increased preventative care.

1. A Proposal for an
Onondaga County
International Medical Graduate
Training Program
Prepared by Matt Cortese, MD/MPH Candidate
SUNY Upstate Medical University
Office of Diversity & Inclusion
For the Healthcare Initiatives for
Community Inclusion Committee (HCIC)
3 June 2014

2. “Water, water everywhere, and
not a drop to drink”
- Adapted from The Rime of the Ancient Mariner
by Samuel Taylor Coleridge, 1798
“Doctors, Doctors Everywhere, and
not a single job”

3. Presentation Outline
• Building the Case: The Problems We Face
• Health disparities
• Socioeconomic inequalities
• Healthcare professional shortages
• Shortage of physicians in Syracuse
• Shortage of minority physicians
• The Solution: An IMG Training Program
• The UCLA Model
• Program Components

4. Building the Case: The Problems We Face
• Problem #1: disparities in health and socioeconomic status in
underserved communities in the City of Syracuse
• There are numerous health disparities, including in mortality rates and
preventable hospitalizations
• There are also gaps in educational attainment, income, medical insurance
rate,
• Problem #2: underutilization and unemployment amongst the
local new American population in Syracuse
• This includes 90+ healthcare professionals and International Medical
Graduates (IMGs)*
• Problem #3: shortage of primary care physicians in impoverished
communities in Syracuse (MUAs and HPSAs**), especially physicians
from underrepresented minority demographic groups.
*IMGs = International Medical Graduates, who are physicians trained in their native country

5. Problem #1: Health Disparities
• There are significant epidemiologic health disparities in the City of Syracuse
• Age-adjusted mortality and premature death rates are about 2.5 times higher for non-whites
than whites in Onondaga County
• Differences in socioeconomic status undoubtedly play a significant role in these disparities

6. Problem #1: Health Disparities

7. Problem #1: Socioeconomic Disparities

8. Problem #2: Underutilization and Unemployment
Amongst Highly-Skilled Syracuse new Americans
• The City of Syracuse is a listed resettlement and migration site,
with about 800 refugees arriving on an annual basis
• As of last year, approximately 12,000 new Americans, including
new and former refugees, currently reside in Syracuse, according
to the Interfaith Works Center for New Americans.
• Included in this population are healthcare professionals, with ~90
qualified healthcare providers arriving since 2011 alone
• This also includes highly skilled physicians, including primary care
practitioners and surgeons, most notably from Cuba

9. Problem #3: Need for Health Services
• There is a critical shortage of primary care physicians in Syracuse,
especially poor communities
• Onondaga County has 8 census tracts within it that are identified as
Medically Underserved Areas (MUAs), with an average score of 55.73.
• 7 of these 8 MUAs are located in the City of Syracuse
• An MUA uses an Index of Medical Underservice (IMU), and ranges from 0
(completely underserved) to 100 (completed served), with a score less than 62
designated as an MUA
• Metropolitan areas are split into Census Tracts representing neighborhoods
with similar demographic and socioeconomic characteristics

10. Problem #3: Need for Health Services
City of Syracuse,
Onondaga County,
New York State

11. Problem #3: Healthcare Workforce Diversity
• Based on U.S. population
American physicians and surgeons
are :
• Overrepresented in both Asian
and White racial demographic
groups
• Underrepresented in Hispanic
and Black demographic groups
• Only 8% of physicians in NYS are
among an underrepresented
minority demographic group
• These physicians are
disproportionately located in
urban HPSAs

12. Problem #3: Healthcare Workforce Diversity
Source: Gray & Stoddard 1997, Journal of Community Health
• Minority patients tend to prefer
minority physicians over non-minority
physicians, especially
those of Hispanic ethnicity
• Personal preference and
language compatibility, not
simply geographic
convenience, are factors
• Racial and ethnic
concordance between
patients and physicians has
been shown to increase in
#’s of participatory visits,
patient satisfaction, and
receipt of preventive care.

13. The Solution: An International Medical
Graduate (IMG) Training Program
• The creation of a pre-residency IMG training program to
help IMGs in our local community become contributing
members of our healthcare workforce in Syracuse
MUAs/HPSAs
• In other words, create a “pipeline” for IMGs into the
American healthcare workforce

14. A Working Model: UCLA
• The David Geffen School of Medicine at UCLA is currently
developing an IMG pre-residency training program for the same
problem
• This program is designed to develop a workforce of bi-lingual, bi-cultural
IMG physicians to address similar shortages of healthcare
professionals (HPSAs/MUAs), particularly minority practitioners
• High-intensity full-time program
• The ultimate goal of the program is to place qualified IMGs in
Family Medicine residencies, particularly in HPSA/MUA areas

15. Proposed Program Components
• Intensive English as a Second Language (ESL) Training
• Includes TOEFL (Test of English as a Foreign Language) exam prep
• Shadowing/observation opportunities in American healthcare settings
• Electronic Medical Record (EMR) Training
• USMLE exam preparation courses and materials for board certification
• Short-term – provide study materials and financial assistance for review
courses
• Long-term – establish pipeline for local IMGs with local residency
programs

16. Why It Will Work for Syracuse
• Critical need for healthcare professionals in Syracuse (7
HPSAs)
• IMGs have been shown to be more likely to work in
metropolitan MUAs as compared with American-trained
physicians
• Minority physicians are underrepresented, comprising only
8% of all physicians in NYS, while minorities comprise 29%
of the NYS population
• Increasing the number of minority physicians will help to
improve healthcare quality and access for minorities in
Syracuse, which comprise nearly 30% of the City’s population
and many of whom live in an HPSAs/MUAs

17. Why It Will Work for Syracuse (continued)
• Syracuse is an established resettlement site for refugees, including 90+
healthcare professionals arriving since 2011 alone
• Literacy organizations that provide ESL training already exist in Syracuse
• Syracuse has 4 hospitals and a medical school (SUNY Upstate) that already
provides USMLE preparation courses and pre-residency training
• Expanding primary care access and preventive services have been shown to
reduce long-term healthcare costs – an important concern in the current
political and socioeconomic climate

18. Potential Obstacles and Solutions
• English proficiency can take years to master, particularly at the high level
demanded of medical professionals
• Expanding funding to literacy-promotion groups may help address this problem
• Collaboration with local literacy groups may help with this
• Barring policy changes that allow for adequate, steady funding or
reimbursement to participating institutions, the cost of USMLE and ESL
preparation classes may not be recouped at the program level
• Grants or reimbursement/tax-credit legislation for IMG training programs would help
alleviate costs.
• Graduate Medical Education (GME) residency slots have not expanded
proportionally with population growth or medical school graduation rates
• This means that residency slots for IMGs will become increasingly competitive
• Can be addressed by additional funding of GME residency positions, especially in
much-needed primary care fields

19. Implementation Steps
• Reach out to local residency programs (GME offices)
• Focus groups with new American IMGs
• Reach out to community to be served to assess local
healthcare needs

20. By providing meaningful career development tools
to highly skilled new Americans, this program will:
• Help reduce underemployment for highly-skilled
new Americans while building the healthcare
workforce in HPSAs/MUAs
•Help combat health disparities by providing care
in the poorest communities in Syracuse

21. References:
• 1. Calman N, Hauser D, Forte G, ContinelliT. New york state physicians: Characteristics and distribution in health professional shortage areas.
Journal of Urban Health. 2007;84(2):307-309.
• 2. Cooper-Patrick L, Gallo JJ, Gonzales JJ, et al. Race, gender, and partnership in the patient-physician relationship. JAMA. 1999;282(6):583-589.
• 3. Doescher MP, Saver BG, Franks P, Fiscella K. Racial and ethnic disparities in perceptions of physician style and trust. Arch Family Med. 2000.
• 4. Gray B, Stoddard JJ. Patient-physician pairing: Does racial and ethnic congruity influence selection of a regular physician? J Community Health.
1997;22(4):247-259.
• 5. Johnson RL, Roter D, Powe NR, Cooper LA. Patient race/ethnicity and quality of patient-physician communication during medical visits. Am J
Public Health. 2004;94(12):2084-2090.
• 6. Komaromy M, Grumbach K, Drake M, et al. The role of black and hispanic physicians in providing health care for underserved populations. N
Engl J Med. 1996;334(20):1305-1310.
• 7. Onondaga Citizens League. How inequality makes us sick: The growing disparities in health and health care. . 2007;28.
• 8. Robert Wood Johnson Foundation. County health rankings and roadmaps. http://www.countyhealthrankings.org/app/new-york/
2014/rankings/onondaga/county/outcomes/overall/snapshot. Updated 2014. Accessed June 3, 2014.
• 9. Saha S, Komaromy M, KoepsellTD, Bindman AB. Patient-physician racial concordance and the perceived quality and use of health care. Arch
Intern Med. 1999;159(9):997-004.
• 10. Shi L, Macinko J, Starfield B, Politzer R, Xu J. Primary care, race, and mortality in US states. Soc Sci Med. 2005;61(1):65-75.
• 11. Turner CB, Turner BF. Who treats minorities? Cult Divers Ment Health. 1996;2(3):175-182.
• 12. UCLA. International medical graduate program rationale. http://fm.mednet.ucla.edu/IMG/about/about.asp. Updated 2012. Accessed June 3,
2014.
• 13. Van Ryn M, Burke J. The effect of patient race and socio-economic status on physicians' perceptions of patients. Soc Sci Med. 2000;50(6):813-
828.
• 14. Xu G, Fields SK, Laine C, Veloski JJ, Barzansky B, Martini CJ. The relationship between the race/ethnicity of generalist physicians and their care
for underserved populations. Am J Public Health. 1997;87(5):817-822.
• 15. Zerehi R. How is a shortage of primary care physicians affecting the quality and cost of medical care? A comprehensive evidence review. .
2008.
• 16. Morrow C, Shultz R. 2013 onondaga county community health assessment and improvement plan. . 2013.