Comparing International and United States Undergraduate Medical Education and Surgical Outcomes Using a Refined Balance Matching Methodology

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The aim of this study is to compare surgical outcomes of international medical graduates (IMGs) and United States medical graduates (USMGs).

Summary of Background Data:

IMGs represent 15% of practicing surgeons in the United States (US), and their training pathways often differ substantially from USMGs. To date, differences in the clinical outcomes between the 2 cohorts have not been examined.


Using a unique dataset linking AMA Physician Masterfile data with hospital discharge claims from Florida and New York (2008–2011), patients who underwent 1 of 32 general surgical operations were stratified by IMG and USMG surgeon status. Mortality, complications, and prolonged length of stay were compared between IMG and USMG surgeon status using optimal sparse network matching with balance.


We identified 972,718 operations performed by 4581 surgeons (72% USMG, 28% IMG). IMG and USMG surgeons differed significantly in demographic (age, gender) and baseline training (years of training, university affiliation of training hospital) characteristics. USMG surgeons performed complex procedures (13.7% vs 11.1%, P < 0.01) and practiced in urban settings (79.4% vs 75.6%, P < 0.01) more frequently, while IMG surgeons performed a higher volume of studied operations (50.7 ± 5.1 vs 57.8 ± 8.4, P < 0.01). In the matched cohort analysis of 396,810 patients treated by IMG and USMG surgeons, rates of mortality (USMG: 2.2%, IMG: 2.1%; P < 0.001), complications (USMG: 14.5%, IMG: 14.3%; P = 0.032), and prolonged length of stay (pLOS) (USMG: 22.7%, IMG: 22.8%; P = 0.352) were clinically equivalent.


Despite considerable differences in educational background, surgical training characteristics, and practice patterns, IMG and USMG-surgeons deliver equivalent surgical care to the patients whom they treat.

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