How medicine has changed! Twenty-six percent of all physicians are now FMGs, as are 58% of primary care doctors, 37% of internists, approximately 45% of medicine residents, and 45% of all physicians in New Jersey (where I was); 51% of rheumatology fellowship positions were filled by non-U.S. graduates in the 2010 match. They are still, however, subject to bias as fellowship candidates; American graduates and even Americans graduated from foreign medical schools are viewed as more desirable than FMGs.
In my previous position, I explicitly addressed this when writing letters of recommendation for my FMG residents, pointing out that, for most of these outstanding, accomplished individuals, it was only an accident of birth that kept them from Harvard, Yale, Johns Hopkins, or USC. Perhaps this helped us achieve success rates for fellowships that exceeded that of even American grads.3 For us, these were people who were selected for medical school by competitive exams from population pools larger than for American medical schools, individuals who were often already trained in medical or other specialties, physicians who successfully passed competitive exams and adapted to a new culture. Would anyone thoughtful really presume to argue that the top few graduates of the medical school in Beijing, for example, which accepts the best 30–40 students each year, by competitive exam, from the most populous countries on the planet, would be less smart or even less well prepared than our medical students?
Therefore, I am not the least bit surprised that the performance of FMGs on the certifying examination of the American Board of Internal Medicine slowly became to equal and even slightly surpass that of American graduates. And I am not the least bit surprised to read that the quality of care (mortality for patients with congestive heart failure and myocardial infarctions, and length of stay in the hospital) provided by FMGs equaled that of American graduates and exceeded that of American graduates of foreign medical schools.4 These results may be even more impressive given that FMGs tend to train at less “prestigious” programs than American graduates.
The lessons, I think, are obvious. We should see increasing numbers of FMGs as fellows and future colleagues (until or unless graduate medical education in this country is transformed) and we should certainly welcome them as colleagues. Deana Lazaro at SUNY Downstate, Sharon Kolasinski at the University of Pennsylvania, Rick Brasington at Washington University, Alan Baer at SUNY Buffalo, and Ellen Gravellese at the University of Massachusetts all appreciated this and matched residents from my former program in recent years. After all, we’re all just people—or, in our case, rheumatologists.
Are There Patients With Inflammatory Disease Who Do Not Respond To Prednisone?
Have you ever had a patient you expected to respond to steroids not do so? I have. I first learned this as a fellow at the old Robert Brigham Hospital, seeing a lupus nephritis patient with Peter Schur. Despite “industrial-dose” prednisone, the patient did not improve. We were taught that when such patients did not manifest the anticipated physical and metabolic changes of corticosteroid administration (Cushingoid features, increase in appetite, weight gain, insomnia, leukocytosis, eosinopenia, and lymphopenia) to suspect unusual inability to convert prednisone to prednisolone, its active metabolite (the keto group at position 11 must be converted to a hydroxyl group before any glucocorticoid activity is exhibited). We offer such patients a trial of methylprednisolone therapy when we consider steroid therapy most appropriate for their condition before utilizing other antirheumatic, antiinflammatory, or so-called immunomodulatory/immunosuppressive (“second line”) agents.5
