Foreign medical graduates To the editor: There is no question that the inflow of foreign medical graduates (FMGs) to the United States will be restricted in the near future. Between 1963 and 1973 the number of FMGs practising in the US increased 131%' and, although the entry of FMGs, particularly those from developing nations, has decreased since, one cannot expect it to stop. However, an . la carte postgraduate medical training menu may no longer be available to them at American hospitals and other medical facilities; they may have to settle for table d'h6te. "Reverse foreign aid" will no longer be acceptable. If the US supposedly finds itself in a medical manpower dilemma - the presence of FMGs serves as a reminder of this - the eventual restriction in residency programs might help. (The current policy recommendations require available residency programs to be not greater than 155% of current residency openings in 1977, 140% in 1978 and 125% in 1979. This arrangement is calculated to ensure that FMGs account for a maximum of 25% of medical postgraduate training posts.1) After World War II the US attracted many FMGs who wanted postgraduate medical education. The original intention was to train these FMGs so that when they returned to their own countries they would be an asset to their medical care systems. As it turned out, the poor nations literally subsidized American medicine.3 The ethical aspect of this was questioned4 and it created a paradoxical situation. Many unaffiliated hospitals opened their doors to FMGs. Training was supposed to be the key to their programs but this was not always the Contributions to the Correspondence section are welcomed and if considered suitable will be published as space permits. They should be typewritten double spaced and, except for case reports, should not exceed 1½ pages In length.
case. FMGs in this situation made the most of what was offered. They were blamed for being practical and were described as inadequate. Worse still, some American medical authorities made generalizations that left the impression that all FMGs, including those in prestigious medical centres and those fully licensed, were lacking necessary skills to be competent in the US.2 To say that open admission to medical schools is universal is erroneous. Competition among applicants to medical school was observed in practically all countries sending FMGs to the United States.6 Implementation of an open-admission policy, of course, may vary. Medical training, academic activities and clinical exposure may differ, but usually the preparation of medical doctors is geared to meeting the health needs of the people of their respective countries.7 Differences in training cannot be equated with incompetence. In this respect no country can claim medical superiority. However, the US has distinct advantages in medical technology over "developing" nations, which send to it the majority of FMGs. It would be ideal if the differences could be harmonized through an educational exchange participated in by all regions of the world. The US could be an effective leader in innovative medical education while providing enough medical elbow-room for the FMGs it sought, attracted and convinced to be a part of American medicine. This could be achieved through an international approach with multilateral agreements, implemented through institutional linkages with cooperation among governments, international organizations and private organizations and foundations. Such an arrangement would produce valuable relations: exchange between two or more institutions tends to reduce, if not eliminate altogether, some of the "rough edges on personal arrange-
ments".8 Since visible and firm commitment is forged between institutions, eventual return home of trainees and full use of their training received abroad are more likely. Participating governments and institutions, international organizations and foundations carrying out medical postgraduate training must induce a sense of regionalism among themselves.9 Training facilities and exchange programs must dovetail with the needs of certain identifiable regions. Provision of medical care must be realistic in order for the disquieting effect of "brain drain" from developing to developed nations to be reduced. Some projects are yielding appreciable results. The World Health Organization (WHO) awarded 3712 fellowships in 1974; 2269 recipients undertook their studies in countries situated in their home region. The WHO regional office in Africa reported that in 1972 82% of award recipients received basic medical training and education in institutions within the region. This was an impressive record considering that in 1962 only 7.2% studied in the region.10 The United Nations Development Program has initiated studies to improve mechanisms for coordinating assistance projects to developing nations, with emphasis on developing regional ties." Some existing cooperative programs are achieving the goal of international education and training. The International Centre of Theoretical Physics at Trieste, established in 1964 by the International Atomic Energy Agency, is a good example. By means of cooperative relations with 20 research institutions and centres throughout the world the centre affords scientists and the international professional staff interplay of ideas, knowledge and expertise.'2 It also attempts to dissipate the sense of isolation that scientists and experts experience upon return to their
CMA JOURNAL/JANUARY 22, 1977/VOL. 116 127
own countries. The arrangement calls for continuing education for at least 5 years. The United Nations and its agencies have stressed the importance of international education through collaborative efforts. Manpower development and improvement of the technical infrastructure of developing nations are given top priority,13 but their perceived technical requirements and needs must be gauged more by internal results attained than by "external inputs supplied".14 The Rockefeller and Ford foundations have assisted the University of East Africa and have provided funds for a special lectureship program. Young Africans trained abroad are attracted to return to play crucial roles in developing the university. The University of Khartoum had made arrangements with the University of London to exchange fellows for staff development. The Catholic University in Chile was aided in allowing exchange of fellows and staff for study at the University of Chicago. There is no question that the accelerated infusion of competent and qualified professionals has benefited many developing nations.15 Proposals have been made to induce FMGs to return to their own coun-
tries. Suter16 has urged coordination in the country of origin, with establishment of bilateral agreements between institutions and government, and provision of fiscal support for graduate medical education. If America no longer needs physicians to man its hospitals because it has inaugurated elaborate plans to increase enrolment of students in its medical schools, educational exchange programs involving FMGs could become true instruments of international understanding. Provided with incentives and needed assistance, many of the FMGs in the US would be more than willing to serve in an international medical exchange. PAnuclo R. MAMOT, PH D Wishard Memorial Hospital Indiana University Medical Center Indianapolis, IN
References 1. Health: United States: 1975, DHEW publ no (HRA) 76.1232, US Dept of Health,
Education and Welfare, 1975, p 104 2. STIMMEL B: The Congress and health man3.
4. 5. 6.
power: a legislative morass. N Engi I Med 293: 68. 1975 BucHaR RM: Nationalism and medicine (E). I Med Educ 48: 1030, 1973 BERGEN SS, BARBARA MD: The foreign medical graduate as a medical resource. Arch Intern Med 135: 1613, 1975 CAMPOS ME: Support of foreign fellows. N Engl I Med 284: 1216, 1971 DAizo U: Medical education in Japan, in World Trends in Medical Education, PURCELL L (ed), Baltimore, Johns Hopkins, 1Q71
n 140
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BELLEVILLE,ONTARIOK8N5E9 128 CMA JOURNAL/JANUARY 22, 1977/VOL. 116
7. HALL T: Health Manpower in Peru: A Case Study in Planning, Baltimore, Johns Hopkins, 1969, p 281 8. SMUCKLER RH: Institutional linkages: a key to successful international exchange. Ann Am Acad Pol Soc Sci 424: 49, 1976 9. SAs FT: Panel: postgraduate training programs, in World Trends in Medical Education, op cit, p 214 10. GUILEERT JJA: Contribution of the World Health Organization to the Evolution of Medical Education in the African Region, 1962-72, WHO document HMD/STT/74.4 11. A Study of the Capacity of the United Nations Development System, vol 2, DP/5, 1969, pp 68-9 12. CARTER WD: Study and training abroad in the United Nations system. Ann Am Acad Pol Soc Sci 424: 71, 1976 13. Partners in Development. Report of the Commission on International Development, New York, Praeger, 1969 14. United Nations Development Program. Report of the Administrator for 1974, DP/111, 1974, p 9 15. FLACK MJ: Results and effects of study abroad. Ann Am Acad Pol Soc Sci 424: 111. 1976 16. SUTER E: The foreign medical graduates in the United States: some reflections on physician migration (E). J Med Educ 51: 345, 1976
Corticosteroids prescribed in Mexicali To the editor: A report by Blackburn and Hindmarsh (Can Med Assoc J 114: 299, 1976) concerning medications prescribed for many Canadians by a physician in Mexico rightly indicates that these medications include a corticosteroid, though the identity of the steroid was not determined. I would like to comment on the identity of such corticosteroids. Since 1968 I have been familiar with the work and success of this physician in the therapy of arthritis and asthma. At that time his response to enquiries by myself and by some of his patients concerning the material he prescribed was that it was sodium cromoglycate (Intal, Fisons). Since, however, this drug was still under investigation at that time, I later concluded that this was only a "red herring" to prevent identification of the drug as a corticosteroid. In 1969 a patient showed me one of the tablets prescribed by this physician. It was imprinted with the word "Lepetit" and was a specialty product patented and manufactured by an Italian pharmaceutical company of that name. This product was not available in the United States or Canada but was imported into Mexico. In May 1971 I was advised by that company that Parke, Davis (US) had purchased the patent for this steroid, 16-/.-methylprednisolone, and was introducing it under the trade name of Betapar in 4-mg tablets. Application for entry of this product into Canada was not anticipated. Another corticosteroid imported into Mexico is Betanisone. This appears to be manufactured in Italy, Czechoslovakia or Sweden. The evidence suggests that large doses are given initially and that the doses are tapered once clinical improvement is noted.
case. FMGs in this situation made the most of what was offered. They were blamed for being practical and were described as inadequate. Worse still, some American medical authorities made generalizations that left the impression that all FMGs, including those in prestigious medical centres and those fully licensed, were lacking necessary skills to be competent in the US.2 To say that open admission to medical schools is universal is erroneous. Competition among applicants to medical school was observed in practically all countries sending FMGs to the United States.6 Implementation of an open-admission policy, of course, may vary. Medical training, academic activities and clinical exposure may differ, but usually the preparation of medical doctors is geared to meeting the health needs of the people of their respective countries.7 Differences in training cannot be equated with incompetence. In this respect no country can claim medical superiority. However, the US has distinct advantages in medical technology over "developing" nations, which send to it the majority of FMGs. It would be ideal if the differences could be harmonized through an educational exchange participated in by all regions of the world. The US could be an effective leader in innovative medical education while providing enough medical elbow-room for the FMGs it sought, attracted and convinced to be a part of American medicine. This could be achieved through an international approach with multilateral agreements, implemented through institutional linkages with cooperation among governments, international organizations and private organizations and foundations. Such an arrangement would produce valuable relations: exchange between two or more institutions tends to reduce, if not eliminate altogether, some of the "rough edges on personal arrange-
ments".8 Since visible and firm commitment is forged between institutions, eventual return home of trainees and full use of their training received abroad are more likely. Participating governments and institutions, international organizations and foundations carrying out medical postgraduate training must induce a sense of regionalism among themselves.9 Training facilities and exchange programs must dovetail with the needs of certain identifiable regions. Provision of medical care must be realistic in order for the disquieting effect of "brain drain" from developing to developed nations to be reduced. Some projects are yielding appreciable results. The World Health Organization (WHO) awarded 3712 fellowships in 1974; 2269 recipients undertook their studies in countries situated in their home region. The WHO regional office in Africa reported that in 1972 82% of award recipients received basic medical training and education in institutions within the region. This was an impressive record considering that in 1962 only 7.2% studied in the region.10 The United Nations Development Program has initiated studies to improve mechanisms for coordinating assistance projects to developing nations, with emphasis on developing regional ties." Some existing cooperative programs are achieving the goal of international education and training. The International Centre of Theoretical Physics at Trieste, established in 1964 by the International Atomic Energy Agency, is a good example. By means of cooperative relations with 20 research institutions and centres throughout the world the centre affords scientists and the international professional staff interplay of ideas, knowledge and expertise.'2 It also attempts to dissipate the sense of isolation that scientists and experts experience upon return to their
CMA JOURNAL/JANUARY 22, 1977/VOL. 116 127
own countries. The arrangement calls for continuing education for at least 5 years. The United Nations and its agencies have stressed the importance of international education through collaborative efforts. Manpower development and improvement of the technical infrastructure of developing nations are given top priority,13 but their perceived technical requirements and needs must be gauged more by internal results attained than by "external inputs supplied".14 The Rockefeller and Ford foundations have assisted the University of East Africa and have provided funds for a special lectureship program. Young Africans trained abroad are attracted to return to play crucial roles in developing the university. The University of Khartoum had made arrangements with the University of London to exchange fellows for staff development. The Catholic University in Chile was aided in allowing exchange of fellows and staff for study at the University of Chicago. There is no question that the accelerated infusion of competent and qualified professionals has benefited many developing nations.15 Proposals have been made to induce FMGs to return to their own coun-
tries. Suter16 has urged coordination in the country of origin, with establishment of bilateral agreements between institutions and government, and provision of fiscal support for graduate medical education. If America no longer needs physicians to man its hospitals because it has inaugurated elaborate plans to increase enrolment of students in its medical schools, educational exchange programs involving FMGs could become true instruments of international understanding. Provided with incentives and needed assistance, many of the FMGs in the US would be more than willing to serve in an international medical exchange. PAnuclo R. MAMOT, PH D Wishard Memorial Hospital Indiana University Medical Center Indianapolis, IN
References 1. Health: United States: 1975, DHEW publ no (HRA) 76.1232, US Dept of Health,
Education and Welfare, 1975, p 104 2. STIMMEL B: The Congress and health man3.
4. 5. 6.
power: a legislative morass. N Engi I Med 293: 68. 1975 BucHaR RM: Nationalism and medicine (E). I Med Educ 48: 1030, 1973 BERGEN SS, BARBARA MD: The foreign medical graduate as a medical resource. Arch Intern Med 135: 1613, 1975 CAMPOS ME: Support of foreign fellows. N Engl I Med 284: 1216, 1971 DAizo U: Medical education in Japan, in World Trends in Medical Education, PURCELL L (ed), Baltimore, Johns Hopkins, 1Q71
n 140
DAN DI.UFF PELLICULES
I
DANDRUFF PELIACULES
'.sebuIe. .K A S.
*
ES
.
S
5
.5
SO
*
S
555
**
S
PHARMACCUTICALS
BELLEVILLE,ONTARIOK8N5E9 128 CMA JOURNAL/JANUARY 22, 1977/VOL. 116
7. HALL T: Health Manpower in Peru: A Case Study in Planning, Baltimore, Johns Hopkins, 1969, p 281 8. SMUCKLER RH: Institutional linkages: a key to successful international exchange. Ann Am Acad Pol Soc Sci 424: 49, 1976 9. SAs FT: Panel: postgraduate training programs, in World Trends in Medical Education, op cit, p 214 10. GUILEERT JJA: Contribution of the World Health Organization to the Evolution of Medical Education in the African Region, 1962-72, WHO document HMD/STT/74.4 11. A Study of the Capacity of the United Nations Development System, vol 2, DP/5, 1969, pp 68-9 12. CARTER WD: Study and training abroad in the United Nations system. Ann Am Acad Pol Soc Sci 424: 71, 1976 13. Partners in Development. Report of the Commission on International Development, New York, Praeger, 1969 14. United Nations Development Program. Report of the Administrator for 1974, DP/111, 1974, p 9 15. FLACK MJ: Results and effects of study abroad. Ann Am Acad Pol Soc Sci 424: 111. 1976 16. SUTER E: The foreign medical graduates in the United States: some reflections on physician migration (E). J Med Educ 51: 345, 1976
Corticosteroids prescribed in Mexicali To the editor: A report by Blackburn and Hindmarsh (Can Med Assoc J 114: 299, 1976) concerning medications prescribed for many Canadians by a physician in Mexico rightly indicates that these medications include a corticosteroid, though the identity of the steroid was not determined. I would like to comment on the identity of such corticosteroids. Since 1968 I have been familiar with the work and success of this physician in the therapy of arthritis and asthma. At that time his response to enquiries by myself and by some of his patients concerning the material he prescribed was that it was sodium cromoglycate (Intal, Fisons). Since, however, this drug was still under investigation at that time, I later concluded that this was only a "red herring" to prevent identification of the drug as a corticosteroid. In 1969 a patient showed me one of the tablets prescribed by this physician. It was imprinted with the word "Lepetit" and was a specialty product patented and manufactured by an Italian pharmaceutical company of that name. This product was not available in the United States or Canada but was imported into Mexico. In May 1971 I was advised by that company that Parke, Davis (US) had purchased the patent for this steroid, 16-/.-methylprednisolone, and was introducing it under the trade name of Betapar in 4-mg tablets. Application for entry of this product into Canada was not anticipated. Another corticosteroid imported into Mexico is Betanisone. This appears to be manufactured in Italy, Czechoslovakia or Sweden. The evidence suggests that large doses are given initially and that the doses are tapered once clinical improvement is noted.
