International Medical Graduate Physician Deaths From COVID-19 in the United States

This case series study examines mortality rates due to COVID-19 among all physicians and international medical graduate physicians in the US.


Introduction
With more than 26 million confirmed cases of COVID-19 and 400 000 deaths by February 2021, the US has the largest reported disease burden in the world. 1 Physicians are among the many who have died of this infection.International medical graduates (IMGs) constitute 25% of practicing physicians in the US and often practice in locations and specialties less preferred by US medical graduates (USMGs). 2 We report on physician mortality from COVID-19, and on mortality of IMGs in particular.

Methods
This case series study followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guideline.All analyses used public information related to deceased physicians.Institutional review board approval was not sought based on federal guideline 46.102 (e) (1), which defines human study participants research as involving living individuals, and in compliance with Stanford University's policy. 3ta on deceased US physicians were downloaded on November 23, 2020, from 3 projects tracking health care worker deaths due to COVID-19: MedPage Today (investigative and voluntary reporting; launched April 8, 2020), Medscape (voluntary reporting requiring verifiable information;

+ Supplemental content
Author affiliations and article information are listed at the end of this article.
Open Access.This is an open access article distributed under the terms of the CC-BY License.

Discussion
In this case series, the proportion of IMGs among physicians (many of whom worked in primary care) who died from COVID-19 was higher than their national proportion among practicing US physicians.
A possible reason for this is the observation that the majority of physician deaths occurred in states with relatively larger proportions of IMGs, which were also the states with higher incidence of COVID-19 at the onset of the pandemic.It is also possible that IMGs in a few states (eg, New York) had higher exposure to COVID-19 because of their practice settings; 40% of IMGs work in primary care. 4ese findings mirror a report from the UK on the high proportion of immigrants among 18 physicians who died of  This study also had some limitations.No definitive or causal conclusions can be reached because of the small numbers, the observational nature of the data set, and the possibility of infections contracted outside clinical practice. Tresults may not be generalizable to data sets from later stages of the pandemic because of the use of telemedicine and improved measures for physician safety.
The larger number of deaths among IMGs highlights their important contribution to patient care.More research is needed to assess the outcomes for IMGs and USMGs during the COVID-19 pandemic.

JAMA Network Open | Health Policy
International Medical Graduate Physician Deaths From COVID-19 in the United States

Figure .
Figure.Proportion of International Medical Graduate (IMG) Physician Deaths Due to COVID-19 by State 2020), and a collaboration between The Guardian and Kaiser Health News (investigation by 70 reporters verifying occupation-related infections; launched April 8, 2020).Obituary and/or news article hyperlinks posted by the 3 projects were researched to verify data (eMethods in the Supplement).Medical school information from DocInfo was used to designate physicians as IMG or USMG.Data on the numbers of practicing IMGs in different states and specialties published by the American Association of Medical Colleges 4 were used as a control distribution for comparisons.Risk ratios were calculated to compare observed proportions within the compiled data set with the control distribution.Two-tailed tests were applied to assess the statistical significance of the ratios at a level of P Յ .05.Pearson correlation was used to explore whether IMGs were disproportionately exposed to the pandemic by comparing state-specific IMG proportions with cumulative COVID-19 case counts on May 1, 2020, because most of the deaths took place in May or earlier.Data analyses were performed using R statistical software version 4.0.3(R Project for Statistical Computing) and SAS statistical software version 9.4 (SAS Institute) from December 2020 to March 2021.

Table .
5hysician Deaths From COVID-19 in the US by SpecialtyThere was a nonredundant total of 132 physician deaths due to COVID-19 from 28 states; of these physicians, 122 (92%) were male; 33 deaths were reported by The Guardian, 84 deaths were reported by Medscape, and 101 deaths were reported by MedPage Today.IMGs constituted 45% (59 of 132) of the deceased, 1.80 times higher (95% CI, 1.51 to 2.21; P < .001)than the 25% national average 2 of IMGs among practicing physicians.New York, New Jersey, and Florida accounted for New York and New Jersey accounted for 39% of US cumulative COVID-19 patient cases on May 1, 2020.5These 2 states had the highest proportions of IMGs among practicing physicians(Figure).