Editor’s Note: Find the latest COVID-19 news and advice in the Medscape Coronavirus Resource Center.

Graduates of international medical schools have died from COVID-19 in disproportionate numbers in the United States in 2020, researchers report.

“I have always thought that international medical graduates [IMGs] in America are largely invisible, ”said senior author Abraham Verghese, MD, MFA, an infectious disease specialist at Stanford University, Palo Alto, Calif. “Everyone knows that there are foreign doctors, but very few know how many there are and also how essential they are in providing health care in America.

IMGs accounted for 25% of all U.S. physicians in 2020, but accounted for 45% of those whose deaths had been attributed to COVID-19 through November 23, 2020, Deendayal Dinakarpandian, MD, PhD, clinical associate professor of medicine at the ‘Stanford University, and colleagues report in JAMA network open.

IMGs are more likely to work in places with high incidence of COVID-19 and in establishments with fewer resources, said Verghese Medscape Medical News. “So it’s no surprise that they were on the front lines when this thing happened,” he said.

To see if their vulnerability affected their risk of death, Dinakarpandian and his colleagues collected data as of November 23, 2020, from three sources of information regarding deaths among doctors: MedPage today, who used investigative and voluntary reports; Medscape, which used voluntary reporting of verifiable information; and a collaboration of The Guardian and Kaiser Health News, which uses investigative journalism.

The Medscape project was launched on April 1, 2020. The MedPage today and The Guardian / Kaiser Health News the projects were launched on April 8, 2020.

Verghese and his colleagues searched for obituaries and news articles referenced by the three projects to verify their data. They used DocInfo to determine the medical schools of the deceased doctors.

After removing duplicates from the lists, researchers counted 132 physician deaths in 28 states. Of these, 59 physicians had graduated from medical schools outside the United States, a number of deaths 1.8 times higher than the proportion of IMGs among American physicians (95% CI, 1.52 – 2 , 21; P <.001>

New York, New Jersey and Florida accounted for 66% of deaths among IMGs, but only 45% of deaths among U.S. medical school graduates.

In each state, the proportion of IMGs among physicians who died was not statistically different from their proportion among physicians in those states, except New York.

Two-thirds of physician deaths have occurred in states where IMGs represent a greater proportion of physicians than in the country as a whole. In these states, the incidence of COVID-19 was high at the start of the pandemic.

In New York City, IMGs accounted for 60% of physician deaths, which was 1.62 times higher (95% CI: 1.26 – 2.09; P = .005) than 37% among New York City physicians overall.

Doctors who were trained internationally often cannot access the most prestigious residency programs or the highest-paying specialties and are more likely to serve in primary care, Verghese said. Overall, 60% of doctors who died from COVID-19 worked in primary care.

IMGs often work in hospitals serving low-income communities and communities of color, which have been hit hardest by the pandemic and where it was difficult to get personal protective equipment, Verghese said.

In addition to these risks, IMGs sometimes experience racism, said Verghese, who received her medical degree from Madras Medical College in Chennai, India. “We’ve actually seen in the COVID era, in keeping with the kind of policy tone that was given to Washington, that there has been a lot more abuse from both foreign doctors and foreign-looking doctors – even if they are not trained abroad – and nurses by patients who have obtained a license. And I want to recognize the heroism of all these doctors.

The study was partially funded by the Presence Center at the Stanford School of Medicine and the Department of Medicine. Verghese is a regular contributor to Medscape. He has served on the advisory board of Gilead Sciences, Inc, is a speaker or speaker bureau member for Leigh Bureau, and receives royalties from Penguin Random House and Simon & Schuster.

JAMA Netw Open. Published online June 11, 2021. Full Text

Laird Harrison writes on science, health and culture. His work has been published in magazines, newspapers and online publications. He is working on a novel on alternative realities in physics. Harrison has taught writing at San Francisco State University, UC Berkeley Extension, and Writers Grotto. Visit him at lairdharrison.com or follow him on Twitter: @LairdH.

For more news, follow Medscape on Facebook, Twitter, Instagram, and YouTube.