I appreciate the comments of each respondent. As Dr. Phillips suggests, I do not side with the "protectionists," and I believe we need quality control to improve the educational experience of international medical graduates in U.S. residency programs. The experiences reported by Dr. Berland and Drs. Sands and Jones clearly buttress the theme of my position paper that we need to do a better job of educating the international medical graduates who enter residency training in the United States. We have a responsibility to the trainees, as pointed out by Dr. Sands and Jones, and I am confident that educational efforts will be appreciated by the trainees, as noted by Dr. Berland.

Dr. Polavarapu is clearly concerned about all aspects of the training process. However, he misinterprets the intent of my paper. I do not have a "negative attitude toward international medical graduates" but firmly believe that the trainees should not be exploited to subserve the service needs of a hospital. They should receive a planned educational experience that will serve a diverse group of individuals. I also disagree that international medical graduates should work in communities of their own ethnic representation and that their acceptance into residencies should reflect their representation in the U.S. population. Residency programs should accept the most qualified international medical graduates, train them in the best possible manner, and enable them to serve either the U.S. population or the population of their own country to the best of their abilities.

In response to Dr. Villalona-Calero, I did not intend to suggest that international medical graduates do not possess the qualities of humanism and ethical behavior that we expect of United States medical graduates. Individuals from diverse geographic and social backgrounds require certain cultural adaptations in order to function appropriately when caring for patients in our society. The issue of financing is a complicated one, and I tried to indicate the complexity involved in any restructuring of the way we fund international medical graduates. A comprehensive payback system for those who train in the United States and then leave is not unreasonable, nor is a payback to one's country of origin if the trainee remains in the United States.