International students in United States allopathic medical education: a mixed-methods analysis of institutional policies

International medical students (IMS; non-U.S. citizens/permanent residents) greatly enhance the diversity of U.S. medical schools and serve in areas of greatest healthcare needs. Despite 15% of the US population being foreign born, international students represent < 2% of US-MD matriculants. Factors that contribute to this underrepresentation of IMS remain unknown. In this study, we analyzed the accessibility, quality, and inclusivity of publicly available admissions and financial aid policies at all US-MD schools, with the goal of evaluating potential institutional and informational barriers faced by IMS. Institutional webpages and American Association of Medical College (AAMC) databases were searched from May-July 2023 to gather IMS-specific admissions and financial aid information from 153 accredited US-MD schools. Two-tailed t-test or chi-square analysis was used to examine differences. An inductive thematic approach was used to qualitatively categorize institutional webpage friendliness. While 45% (69/153) of U.S.-MD schools reported accepting IMS, only 18% (27/153) admitted students without restrictions (e.g., Canadians only, state/religious preference). Further, 38% (26/69) of the schools that accept IMS did not provide financial aid information, while nearly two-thirds of the remaining schools required proof of personal financial ability with no institutional/federal support. International students also entered schools with a higher average Medical College Admission Test (MCAT) score and Grade Point Average (GPA). In the national AAMC databases, 19 additional programs were listed as accepting IMS although the institutional webpages stated otherwise; the databases also lacked details on specific restrictions posed by the majority of institutions. Of all 153 webpages, only 14% were deemed 'international friendly.' Restrictive admissions and financial aid policies as well as the poor quality and access to information are major barriers that affect IMS. Strategies that aim to overcome these challenges can greatly help advance diversity, equity, and inclusion in medical education.