I applied to 36 programs for residency, and on the very first day of application review, I got rejection letters from 20.
But as an International Medical Graduate (IMG), my experience was not unique. In the NRMP 2022 Program director’s survey, about 50% of program directors indicated that they “seldom” interviewed IMGs or Foreign Medical Graduates (FMG). Twenty percent of program directors responded that they never interview U.S.-citizen IMGs, and 34% indicated the same for non-U.S.-citizen IMGs. Imagine spending all the time, money, and effort required to complete medical school, just to be eliminated from consideration as part of “standardized screening.”
An IMG is a physician who completed their medical education outside the U.S. or Canada. FMGs are graduates who are not American citizens or permanent residents, and who have completed their medical schooling outside the U.S. FMGs account for 60% of IMGs. In order to work or train in the U.S., FMGs must first get a visa.
I am an “alien physician,” as the U.S. Citizenship and Immigration Services calls me. And despite the challenges of become a practicing physician in the U.S., I am one of the many IMGs and FMGs here. One in every four physicians in the U.S. is an IMG, and the AAMC reported that 42.3% of hospitalists in the U.S. were IMGs in 2013. We are a critical part of the health care system and contribute significantly to scientific development, research, and most importantly, quality patient care, with fewer patients dying in our care than in that of U.S graduates.
The AMA predicts a shortage of up to 124,000 physicians in the U.S. by 2034, primarily impacting most underserved and disparate populations in America. Even at present, FMGs disproportionately serve the most underserved regions and specialties of the U.S. The prevalence and need for FMGs at the frontlines was further highlighted by the COVID-19 pandemic. While filling a gaping void in the U.S.' health care workforce, immigrant physicians also contribute unique insights, cultural knowledge, and linguistic skills that are crucial in the care of a vast and heterogenous patient population.
But it all begins with the USMLE Steps, regardless of the physician’s prior experience or training.
Though I managed to get high scores on my USMLEs, which should have given me a competitive edge, I quickly learned that without U.S. clinical experience and letters of recommendation, my scores meant nothing. So, I applied for electives and observerships in the U.S. Little did I know at that time how lucky I was to have obtained a visa to sponsor these experiences, as there are not a lot of hospitals willing to sponsor a foreign medical student with no clinical experience in the U.S. I was also fortunate enough to have found preceptors who offered to write strong letters to support my ERAS application. And then I received my 20 rejections in one day.
Thankfully, the academic institution where I had completed electives recognized my capabilities and offered me a “pre-Match,” which made me one of the few to have a residency position. About half of IMGs who apply to the Match are left to question their life decisions. The ones who do get selected are dependent on their institutions to sponsor their stay in the country, which in most cases is a time bound J1 or “alien exchange” visa. This is contingent upon our returning to our home country after a period of training lasting no longer than six years. Alternatively, the physician may choose to work in an underserved region for three years before they can even apply for permanent residency. But there is a catch. Each state has only a limited number of these “waiver” H1B positions per year and the processing time is several months. So you complete years of training and get offered your dream job in a community that really needs you, only to realize that you may not be able to secure a visa to remain in the country.
My husband applied for a waiver H1B position at the same time as I did. His waiver visa was rejected and he had to go back to India for a year before he could apply again. Meanwhile, I got to work at an amazing academic practice with supportive leadership. I was the exception, not the rule. Most employers who offer these waiver jobs are well-aware that IMGs are dependent on their continued employment to be able to stay in the country, which often results in lower salaries, unfair schedules, and higher workloads. Even with fair employers, unpaid leaves at any time put you at risk for losing your visa. I missed out on attending my brother’s wedding in India because my J1-waiver application was in process, and I couldn’t leave the country. I volunteered at COVID-19 testing and vaccination clinics here, but when my own dad got hospitalized during the pandemic, I couldn’t leave the country to go see him because I would need a new visa stamp to come back and there were no visa stamping appointments. Thankfully, he recovered. My friend’s premature infant ended up being in the NICU for months, but she had to restrict to six weeks of maternity leave because if she lost her visa, she wouldn’t be able to stay in the same country as her baby.
I am currently applying for permanent residency in the U.S. The maximum amount of time one can work on an H1B visa without applying for permanent residency is six years after completion of training. Some employers will sponsor the FMG’s permanent residency application, but even then most will apply right around the six-year deadline. This is through the “employer-sponsored EB2 process.” Once an EB2 application is submitted, the average wait time to actually get a permanent residency is 11 years (23 years after starting residency), or more if the FMG is from one of the countries that are responsible for sending the most physicians to the U.S. (India, China, the Philippines, etc.).
I am also working on developing my profile for the EB1 process for permanent residency — the famous “Einstein Visa.” This process is much shorter, but the only eligible physicians are those who prove to have an “extraordinary ability.” Unless you are a presidential spouse or a Hollywood A-lister, this includes the need for hundreds of citations, groundbreaking research, media attention, leadership roles in professional societies, and worldwide acclaim. I am working hard to meet these criteria despite not being eligible for any major research grants by virtue of not being a citizen of the U.S., and thus no research FTE opportunities. I often question if and when I will be considered good enough.
Until I receive citizenship, I, like seven percent of physicians practicing in the U.S., will hope to continue to be here on a temporary visa. I live in the uncertainty of whether my visa will be renewed next time. I have been informed by the occasional patient or caregiver that they just couldn’t trust someone who wasn’t an American. When I apply for jobs, I am asked to write statements on diversity as part of the application, and then get rejected just because of my immigration status.
At the end of the day though, I am happy. No one owes me anything. I am here of my own accord, and I am so very grateful for the experience. I appreciate how lucky I have been at each step of the process so far. My life is great, and my struggles are nothing compared to others. I have never had to worry about where my next meal is coming from. I love my specialty. I get to be a physician every day and do the work I am most passionate about. I made it. Just like most of you! And yet, when I tell my patients to follow up with me in a year, what I really mean is, “Follow up with me if I am still here.”
If you're an IMG or FMG, how do you approach conversations with patients knowing that your visa may not be renewed?
Dr. Priyanka Bakhtiani is a pediatric endocrinologist at the Children’s Hospital Los Angeles, CA, specializing in the endocrine care of children after cancer therapy. She manages social media and networking for the Southern California Organization of Pediatric Endocrinology and the Pediatric Endocrine Society. She is passionate about medical education and currently pursuing a Masters in Academic Medicine. She loves to go hiking with her husband and foster dogs. Dr. Bakhtiani is a 2022–2023 Doximity Op-Med Fellow.
Acknowledgment: Thank you to my fellow FMGs Drs. Kavitha Bagavathy, Malvika Varma, and Aditya Sharma, for the insights, feedback, and support as I wrote and rewrote this piece.
Image by RamCreativ / GettyImages