The problems of international medical graduates have much in common with the problems associated with international trade in commodities such as pots, pans, and automobiles. Suppose Country A produces more physicians than it can employ, and Country B cannot produce enough physicians who want to train as internists. In a free market, physicians will inevitably migrate from Country A to Country B to fill the vacant training positions in internal medicine.

This entirely predictable state of affairs has been accompanied by much hand-wringing and lamentation, remarkably reminiscent of Detroit's response to imported Japanese automobiles. The debate has mirrored the historic conflict between free traders, who advocate an open door to foreign products while maintaining quality controls and domestic standards, and protectionists, who advocate rigid import barriers and denounce foreigners for taking jobs away from U.S. citizens. Dr. Levey's focus on quality control suggests that his heart does not lie with the protectionists [1].

Adam Smith could explain the economics of the problem, but Elisabeth Kubler-Ross might provide a better insight into its passions. She described the stages of grief in dying patients: denial, anger, bargaining, and depression, followed finally by acceptance [2]. Many of my fellow program directors grieve for internal medicine and fear that it may be in grave peril. Most have progressed beyond denial, but many are still angry, bargaining, and depressed. I (an Australian graduate) counsel that we accept the situation, maintain a free market, improve the quality control of international medical graduates, and resist all the temptations of protectionism. The free movement of physicians will ensure that the best and the brightest continue to emigrate to the United States and that training programs in internal medicine survive and prosper.