The commentaries of Drs. Vasireddi and Chowdappa and Dr. Anwar each contain some valid points. As Dr. Anwar notes, IMGs are not driving the subspecialization rate in the group D programs, where they constitute only 1% of the residents. Earlier work showed that the number of subspecialty programs based in the same institution as the residency program was the major predictor of direct entry into subspecialty training [1]. This number increases greatly as the proportion of IMG residents decreases (group A, 1.84; group B, 2.81; group C, 5.02; and group D, 6.30). This effect is also stronger than the tendency for women (who are more highly represented in program groups C and D than in groups A and B) to subspecialize at a lower rate.

The groups of programs that will be most vulnerable to reductions under graduate medical education reform, however, depends largely on the specific implementation of that reform and is presently unknown. Approaches may include individual programs to respond to local economic and political pressures, may stem from national professional organizations such as the Accreditation Council for Graduate Medical Education or the various boards, or may take the form of national or state legislative action. Currently, all proactive approaches to graduate medical education reform recognize program "quality" as an important guide to program reduction. For the reasons outlined in our report, we believe that as a group, the programs with the highest proportions of IMG residents may be the most subject to questions about "quality." The issues are the following: Can these questions be successfully answered? If so, how? If not, what are the implications for the teaching hospitals involved?

Drs. Vasireddi and Chowdappa raise a somewhat different set of issues, and we agree that IMG residents and physicians play important roles in the U.S. health care system. We also agree that there are dangers in generalizing the behavior of groups [2]. However, IMGs constitute an important policy group. Not only do they (as a group) show different behavior (for example, higher rates of subspecialization), but they also present different problems in training, and, most significantly, they are easily targeted by federal immigration policy. In the current atmosphere of concern in health care about the generalist-specialist mix in the physician work force, we must resist any temptation to make IMGs the scapegoats.