Abstract
BACKGROUND AND OBJECTIVES: International medical graduates (IMGs) are a quarter of US practicing physicians and residents, with higher numbers in family medicine. Our objective was to determine whether the progression of milestone ratings varies between IMGs and US medical graduates based on a residency's historical percentage of IMGs. METHODS: Data, which were all from the American Board of Family Medicine, included milestone ratings of each family medicine graduate from 2018 to 2020. We calculated the mean milestone rating for each core competency at each assessment. The main exposure was the 10-year percentage of residency graduates who were IMGs: very low (<10%), low (10%-33%), medium (34%-66%), and high (67%-100%). We used repeated measures multilevel regression to test for adjusted associations of resident and residency characteristics with milestone performance. Interactions between IMG status and historical percentage of IMGs tested for differential milestone growth. RESULTS: Our sample included 12,302 residents from 538 residencies. Of the family medicine residencies, 41.8% had less than 10% IMGs. Across milestones, mean growth between rating periods ranged from 0.46 to 0.54. In adjusted regression analysis, both being an IMG (β=-0.003 to -0.07) and training in a higher historical IMG residency (β=-0.01 to -0.08) were associated with lower milestone ratings. IMGs in high IMG programs had higher ratings for medical knowledge and professionalism (β=0.07). CONCLUSIONS: We found comparable milestone ratings between IMGs and US medical graduates, with IMGs getting a small boost if they were trained in a program with a higher percentage of IMGs. Our results demonstrate that the performance of IMGs may be enhanced in residencies with a history of acculturating them.