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Variations in Post-Operative Outcomes between Surgeons Who Are US vs International Medical Graduates among Patients Undergoing Surgery for Cancer
*Muhammad Muntazir M. Khan, *Muhammad Musaab Munir, *Selamawit Woldesenbet, *Mujtaba Khalil, *Yutaka Endo, *Erryk Katayama, *Mary Dillhoff, Susan Tsai, *Jordan Cloyd, Timothy M. Pawlik
Surgery, The Ohio State University Wexner Medical Center, Columbus, OH

Background and Objectives: International Medical Graduates (IMG) make up approximately one-quarter of the physician workforce in the United States (US). Nonetheless, implicit biases regarding the quality of training received by IMG surgeons and US Medical Graduate (USMG) surgeons remain prevalent. We sought to characterize post-operative outcomes among patients who underwent an oncologic operation relative to whether the treating surgeon was an IMG versus USMG.
Methods: The 100% Medicare Standard Analytic Files were utilized to extract data on patients with breast, lung, hepato-pancreato-biliary (HPB) and colorectal cancer who underwent surgical resection between 2014 and 2020. A surgeon was categorized as a USMG if the surgeon attended medical school in the US or Puerto Rico, and an IMG surgeon if they attended medical school outside the US or Puerto Rico. Multivariable regression models were performed to evaluate the association between post-operative outcomes among USMG and IMG surgeons, after adjusting for patient-, surgeon-, and hospital-level characteristics.
Results: Among 285,930 beneficiaries (breast: n=19,492, 6.8%; lung: n=71,395, 25.0%; HPB: n=32,471, 11.4%; colorectal: n=162,572, 56.9%), 242,914 (85.0%) and 43,016 (15.0%) underwent surgery by a USMG and IMG surgeon, respectively. Overall, 129,576 (45.3%) individuals were male, and 268,848 (59.1%) patients had a Charlson Comorbidity Index (CCI) score >2. Notably, IMG surgeons were more likely to care for racial/ethnic minority patient subgroups (IMG: 14.7% vs. USMG: 12.5%), those with a high social vulnerability index (IMG: 33.3% vs. USMG: 32.1%), and a CCI score >2 (IMG: 61.0% vs. USMG: 58.7%), as well as patients who required an urgent procedure (IMG: 28.7% vs. USMG: 26.2%) (all p<0.001). On multivariable analysis, patients treated by an IMG surgeon were more likely to experience adverse post-operative outcomes including readmissions within 30 days (OR 1.06, 95%CI 1.04-1.09), post-operative complications (OR 1.03, 95%CI 1.00-1.06), and an extended length of stay (OR 1.05, 95%CI 1.02-1.08) versus USMG surgeons (all p<0.05) (Figure). In turn, patients treated by IMG surgeons had slightly lower odds of achieving a textbook outcome (OR 0.94, 95%CI 0.92-0.96; p<0.001)
Conclusion: Postoperative outcomes among patients treated by IMG surgeons were roughly equivalent to that of USMG surgeons. Notably, IMG surgeons were more likely to care for patients with multiple comorbidities and those from vulnerable communities. In turn, IMGs represent an important surgical task force that may help bridge inequities in the provision of surgical care.

(a) Violin plot demonstrating the association between post-operative outcomes and USMG vs IMG Surgeons.
(b) Proportion of patients that achieved a textbook outcome and its components relative to USMG vs IMG surgeons.
USMG: United States medical graduate; IMG: International medical graduate; LOS: Length of stay.
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