Japanese International Medical Graduates and entrance into US clinical training: Challenges and methods to overcome them

Abstract Introduction Entering US clinical training requires completing requirements and navigating an application process differing from the Japanese system. Additionally, increases to the number of US medical school graduates have increased competition for US residency positions. We examined profiles of Japanese International Medical Graduates (IMGs) who completed US clinical training, the timelines to securing US clinical positions, and the greatest challenges during this process and methods to overcome them. Methods Individual semistructured interviews were conducted with 35 purposively sampled Japanese IMGs. We performed exploratory thematic analysis using iterative data collection and constant comparison. Results Twenty percent of participants lived in a native English‐speaking country during childhood. The United States Medical Licensing Examinations were completed at ages 25‐40 years. Challenges were categorized as: (1) English communication, (2) understanding the application process, (3) motivation to persevere through the process, (4) time management to complete Educational Commission for Foreign Medical Graduates requirements, (5) receiving letters of recommendation and overcoming competition for US residency positions, (6) financial cost of the process. Pragmatic generally self‐dependent methods helped overcome challenges 1‐4 and 6. Participants detailed personal or, more commonly, institutional connections to US training programs required to overcome challenge 5. Conclusions Japanese IMGs pursue US clinical training from diverse backgrounds commonly without the advantage of prior English fluency. Amidst increased competition internationally to enter US residency coupled with cultural and linguistic differences making this challenge often greater for Japanese IMGs, the competition to participate in institutionalized connections to US training programs is anticipated to increase.


| INTRODUC TI ON
Internationally, medical education is rapidly evolving in response to globalization and changing societal needs. 1 American medical education is directly or indirectly influential to Japanese medical education, currently especially in emerging disciplines such as primary care medicine, geriatrics, palliative care, and infectious diseases. [2][3][4] In turn, opportunity for some Japanese physicians to pursue US clinical training is important.
Entering US clinical training requires completing ECFMG (Educational Commission for Foreign Medical Graduates) certification and applying via the ERAS (Electronic Residency Application Service) process, which differ significantly from Japanese systems. 5,6 Distinctions include the submission of a portfolio including examination scores, faculty evaluations, and letters of recommendation in the American application process. 6 Additionally, the ECFMG has mandated that applicants graduate from accredited medical schools as of 2023. 7 Japan is meeting this requirement through establishment and ECFMG recognition of the JACME (Japan Accreditation Council for Medical Education) in 2017, followed by steady accreditation of medical schools across Japan. 8,9 Competition to enter US residency is impacted by the demand medical school students and osteopathic medical students increased by 31% to 21 622 students and by 164% to 8124 students, respectively. 10 Allopathic medical students receive the conventional Doctorate of Medicine (MD), while osteopathic medical students receive a Doctorate of Osteopathy (DO) in a long-standing American physician training landscape that recognizes these slightly differing philosophies. 11 Osteopathic medical students are eligible to take the USMLE and over half matriculate to allopathic residency training programs. 12 During the above interim, the number of US residency positions has increased, but at a slower rate than the applicant population. 10 These developments have increased competition for residency, with manifestations including a greater than 70% increase in the number of applications per residency program. 13 The number of US residency positions exceeds the number of US medical school graduates, meaning there is ample US training opportunity for IMGs (International Medical Graduates). 14 Nonetheless, the competition is stiff. IMGs perform significantly better on the USMLE (United States Medical Licensing Examination) but experience a 51% residency match rate, 35% lower than for US graduates. 14,15 These statistics are roughly unchanged since 2002, 14,16 but because of the increase in applications, residency directors are changing how they screen applicants. Changes include eliminating a holistic review of the applications and raising requirements for applicants invited to interviews. 13 In some cases, residency programs that previously commonly accepted IMGs are now filled by US graduates.
Compared to most IMGs, Japanese face steeper barriers to entering and succeeding in US training, including linguistic distance and the absence of a culture of migration. 4 In these global and local contexts, understanding the challenges and successes of Japanese physicians who have navigated US clinical training is increasingly relevant. Guidebooks exist for Japanese trainees interested in pursuing US training, 17 but a data-driven inductive study has not been performed. In this study of Japanese physicians who have completed US clinical training, we examine the greatest challenges to securing US clinical training positions and methods to overcome them. Relatedly, we examine educational and linguistic backgrounds to help develop profiles of this physician population.

| MATERIAL S AND ME THODS
This report is complemented by a separate report from the same study that examines challenges for Japanese IMGs during US clinical training. 18 Identical participants and methods were used, and the data were collected and analyzed simultaneously.

| Study approach
A qualitative study design, specifically Constructivist exploratory thematic analysis, 19 was selected given our interest in developing a conceptual understanding of which Japanese physicians become US clinically trained and how they achieve this goal. Constructivist methodology recognizes that data collection and interpretation are influenced by researchers' prior knowledge of the subject matter. 20 The primary investigator completed all medical trainings in the United States but worked at a Japanese residency program for 3 years prior to commencing this study. The secondary investigator is a Japanese IMG. Both investigators have completed fellowships in medical education with coursework in qualitative methodology, and the primary investigator has previously conducted qualitative research. Both investigators are employed at US teaching institutions as clinician educators and have contributed to the entrance into and education during US residency for IMGs from many countries including Japan.

| Participant sampling
Japanese IMGs working in the United States and Japan were purposively sampled with the goal of identifying diverse experiences.
In the absence of a comprehensive database of Japanese IMGs, we identified potential participants by (a) asking participants to suggest other potential participants, optimally with experiences contrasting their own, and (b) requesting names of Japanese graduates from training programs in the United States and Japan who had educated Japanese IMGs. Inclusion criteria were graduation from a Japanese medical school and completion of US clinical training within one to fifteen years at time of interview. Additionally, a participant group of approximately 50% returnees to Japan and 50% practitioners in the United States was targeted. These parameters were chosen because separate work examines experiences after US training. Thirty-five of 39 contacted physicians agreed to participate. Each participant provided informed consent. One or both investigators had prior relationships with eleven of the participants but had not previously discussed the issues in this study. The study was approved by the Institutional Review Board at the University of Pittsburgh Medical Center. To enhance readability, we performed minor grammar editing of quotations. We confirmed the themes with two participants as a validity check.

| Participant characteristics
Of the 35 participants, 80% (28/35) never lived in a native Englishspeaking country during childhood. The participants attended 23 distinct medical schools. Roughly half of them participated in a clinical elective in the United States and/or observership at a US Naval Hospital in Japan (USNH). The participants completed the USMLE examinations most commonly during postgraduate year (PGY) 1-2 and entered US training most commonly at age 28-30 years, but the ranges were from the 5th year of medical school to PGY 15 and age 25-40 years, respectively. Table 1     Some of these interviews resulted in prematch residency position offers.

| Challenges and methods to overcome them during preparation for US residency
In addition to the institutional bridges to US residency listed by Participant 13, numerous participants described the value of the 1-year internship at a USNH in Japan; participants received opportunity to improve their fluency in English and American medical practice while also studying for USMLE examinations, letters of recommendation from American physicians, and sometimes opportunity for externships at US teaching hospitals.
If you go outside, it's Japan, but within the hospital, that's all the US, so it's very easy for us Japanese to get used to the US medical system and improve your communication. It's a perfect setting.
Finally, several participants explained making their own connections, either while in Japan, or more often in the case of non-primary care-related fields, moving to the United States and then making connections while pursing research to bolster their resumes. Table 3 lists the connections used to enter US residency with representative quotes.
Participants varied in their recollection of the financial cost of their pursuit of US residency, depending on their use of English classes, test preparation courses, and the number of trips for interviews, but most commonly the estimated total was $10 000 (approximately 1 100 000円). Several participants explained moonlighting or borrowing money for this purpose.

| D ISCUSS I ON
Given the challenge of achieving English fluency for many Japanese and its necessity for US clinical residency, it may be anticipated that Japanese with childhood immersion in English would be overrepresented among Japanese IMGs. However, our findings suggest this is not the case. Rather, they indicate that determination and discipline, as demonstrated by the described time management and financial sacrifice, are the more important personal qualities.
It is also clear from the extensive challenges described by our participants that careful planning is necessary to obtain a US residency position. Our data show that uniform decision making or achievements during medical school and clinical residency in Japan are not required. Participants attended a wide range of medical schools that include varied opportunities for electives abroad. They took the American medical licensing examinations and applied for US residency at diverse ages and stages in their medical careers.
Surrounding oneself with others striving for similar goals was one strategy to enhance motivation.

Male gender 24
Childhood residency a in a native English-speaking country contrasting experiences, we may have missed a subset of Japanese IMGs. In turn, our sampling was at risk of bias.

| CON CLUS IONS
Japanese IMGs derive from diverse training programs at diverse ages and commonly without the advantage of prior English fluency.
Rather, planning, determination, and discipline appear to be the key personal qualities. In their pursuit of US clinical training, Japanese IMGs emphasize the need for connections to the US medical training system and their pathways commonly converged at a limited number of institutional affiliations.

ACK N OWLED G EM ENTS
We would like to express our gratitude for the time and thoughtful comments from all participants, and funding received from the Shadyside Foundation, Thomas H. Nimick Jr Competitive Research Fund.

CO N FLI C T O F I NTE R E S T
The authors have stated explicitly that there are no conflicts of interest in connection with this article.