By Hermina D. Fernandes, MBBS

An innate sense of curiosity for the world that existed beyond the shoreline visible from my bedroom window in my hometown of Mangalore, India, initially inspired me to embark on a journey towards an oncology fellowship in the United States. I obtained my medical degree from Kasturba Medical College, Manipal University, a premier medical institution in India, and then started my pursuit of a residency position in the U.S.

Since 1958, the Educational Commission for Foreign Medical Graduates (ECFMG) must certify international medical graduates (IMGs) in order to pursue advanced medical training in U.S. programs accredited by the Accreditation Council for Graduate Medical Education (ACGME).¹ The vetting procedure for ECFMG certification is rigorous, including primary source verification of medical school credentials, and successfully passing the first two steps of the U.S. Medical Licensing Examination (USMLE),² and an additional Clinical Skills Assessment (CSA) which was introduced in 1998.¹ I am sure most IMGs would tell you that having to re-read basic biochemistry and physiology after having completed medical school could cause one to sit at the end of their bed at night and reconsider their life choices. Thankfully, the lure of training in the U.S., the mecca of medical innovation and research, usually overpowers the inconvenience of duplicative training. Matching into a residency remains highly competitive for IMGs, with only around 57% of IMGs matching into first-year residency positions in 2018.³

Challenges for immigrant physicians

Other than navigating the nuances of immigration—such as acquiring a Social Security number, getting a bank account, finding a residence, getting a U.S. driver’s license, or challenges due to the lack of an established credit history—IMGs face unique cultural hurdles as they start residency training. For example, while training and working in India, I never worked with an electronic healthcare system, carried a pager, dictated elaborate notes with a 10-point review of systems, or arranged for discharge of a patient to a nursing home. This does not mean the standard of care provided in India is sub-par, but just that it has a different organizational structure. Despite having vast clinical experience back home, the initial learning curve in residency is steep for IMGs as even medications have different nomenclature: what I knew as paracetamol was now Tylenol, etc. While residency training is stressful by design, these added factors amplify the challenge for IMGs.

After completing my internal medicine residency at Saint Louis University, I pursued a fellowship in hematology and medical oncology. Matching into a subspecialty fellowship is highly competitive for IMGs. In 2015 (the year I applied for a fellowship), the hematology/oncology fellowship match rate was 58% for IMGs compared to 84% for U.S. medical graduates (USMGs).⁴ Hematology and oncology is innately one of the most competitive fellowships, with a ratio of applicants to positions as high as 7:1.⁵

While USMGs are well acquainted with the arduousness of a residency/fellowship program, additional challenges arising from visa sponsorship requirements are unique to non-U.S. citizen IMGs. The U.S. immigration system allows two visa programs to permit U.S. medical training for foreign nationals—the J-1 visa (U.S. Exchange Visitor Program) and H-1B visa (specialty occupation temporary work visa). J-1 and H-1B visas have a residency time limitation of 7 years and 6 years, respectively, barely adequate to complete a residency program and a subsequent fellowship for subspecialty training.

After completing medical training, J-1 visa holders must return to their home country for 2 years or apply for a federal and state-sponsored waiver of this requirement by agreeing to work in medically underserved areas (MUAs) for a period of 3 years,⁶ with most states requiring IMGs to secure a signed contract almost a year prior to graduation. With most of these positions reserved for primary care physicians, gaining employment is a challenge for the subspecialist. Physicians exhausting their 6 permitted years on H-1B visa status during training find themselves with no remaining time left on H-1B status to practice medicine following training.

Whether IMGs train on J-1 or H-1B status, a pathway to Legal Permanent Residence (LPR) status (commonly referred to as a green card) is not guaranteed, often taking multiple years to complete, especially if the physician is from a country that is subject to substantial backlogs, like India (in which case the process can take decades).⁶ During this waiting period, the physician is stuck in a state of unending uncertainty characterized by a constant fear of falling “out of visa status,” which can even lead to deportation. Furthermore, during this waiting period, physicians lack job portability, forcing them to be in an indentured state of employment, as their employer often sponsors their green card. Prior to obtaining a green card, physicians are also limited in their ability to join/start a private practice, start a business, or even acquire federally funded research grants.

A vital segment of the oncology workforce

Following fellowship training, I was pleased to start my J-1 waiver at Sanford Health in Bismarck, North Dakota, thereby joining the U.S. immigrant oncologist workforce. According to the 2016 American Medical Association (AMA) Physician Masterfile, 23% of practicing physicians in the United States did not graduate from a U.S. or Canadian medical school,² with Indian IMGs being the largest pool.⁷ Currently, 34.4 % of U.S. oncologists are IMGs.⁶

Patients treated by IMGs are more likely to be non-white, poor, covered by Medicaid, and sicker with multiple medical comorbidities.⁸ In areas where more than 30% of the population lives below the federal poverty rate, nearly one-third of all doctors are IMGs.⁶ In areas where per-capita income is below $15,000/year, 42.5% of all doctors are IMGs.⁶ IMGs are concentrated in areas of low socio-economic status; in areas where 10% or less of the population has a college degree, nearly one-third of all doctors are IMGs.⁶ 20.8 million people live in areas where IMGs account for at least half of all doctors.⁶

In a recent study, there was no evidence that patient outcomes for IMGs were worse than those for USMGs,⁸ with patients treated by IMGs demonstrating a lower 30-day mortality than those treated by USMGs.⁸ This prompted a statement by Dr. Andrew Gurman, then president of the AMA, that this study “provides additional reassurance about the high quality of care that international medical graduates deliver in the United States.”⁹

A significant percentage of researchers at leading cancer centers are foreign-born, ranging from 30% at the Fred Hutchinson Cancer Research Center to as high as 62% at the MD Anderson Cancer Center.¹⁰  Overall, 42% of the researchers at the leading seven cancer research centers in America are foreign-born, hailing from more than 50 countries.¹⁰ The first head of the U.S. National Cancer Institute, Dr. Carl Voegtlin, was an immigrant born in Switzerland. Eleven immigrants have served as president of the American Association for Cancer Research. Four immigrant cancer researchers won the Nobel Prize between 1947 and 2009; since 1960, 28 immigrants have won the Nobel Prize in Medicine.^10,11

A study commissioned by the ASCO Board of Directors in 2007 predicted a significant shortage of oncologists in the U.S. by 2020 due to an aging oncology workforce and a shrinking pool of new physicians training in internal medicine.¹² Thanks to progress in our field, the number of U.S. cancer survivors is expected to grow from 15.5 million in 2016 to 20.3 million by 2026, increasing the need for oncologic care.¹² IMGs play a crucial role in filling gaps in the medical workforce, especially in rural areas, and policies that address rural/urban physician maldistribution should take into account the contribution of IMGs.¹³

It is logical to conclude that the “brain gain” experienced by the U.S. by hiring immigrant physicians could lead to “brain drain” in the physicians’ country of origin. As of 2017, 40% of IMGs in the U.S. had attended medical school in countries classified by the World Bank as low- to middle-income countries, many of which suffer from critical shortages of physicians.¹⁴ It is imperative that IMGs engage productively in capacity-building projects, medical volunteerism, and health care education in their countries of origin on completion of training, to harness the full potential of the U.S.-based training they have received. In that vein, I had the honor of being a guest speaker for medical students and residents at my alma mater in India earlier this year. I believe such interactions foster a global exchange of ideas and educate the future generation of doctors across the world.

U.S. immigration policies significantly limit the ability of doctors, including cancer researchers, to immigrate to and practice in the U.S. A few measures that would help increase the impact of IMGs on cancer care in the country include:

• Loosening policies on high-skill immigration for individuals in science, technology, engineering and math (STEM) fields, including doctors
• Simplifying and expanding the J-1 waiver programs to enable subspecialists to serve in MUAs
• Providing a less onerous pathway to LPR for physicians, especially those who serve in MUAs
• Providing access to U.S. National Institutes of Health awards and other federally sponsored grants to deserving IMGs to help further cancer research
• Eliminating per-country caps and long LPR backlogs for physicians from countries such as India and China

IMGs do not practice and reside in U.S. communities with the sole aim of a more lucrative income or better prospects than their home country, but rather aim to assimilate as responsible contributors to the community in which they live. The path to finding new cancer cures requires assimilation of ideas, breaking barriers, and thinking of unconventional ways to solve old problems. Overlooking the critical role that IMGs play in mitigating physician shortages would be detrimental to the future of cancer care in the U.S. IMGs have historically been a source of vitality to the physician workforce with their scientific, clinical, and cultural contributions.¹⁵ Immigrant oncologists can also serve as mentors, volunteers, and facilitators to engage the international oncology community.

I end by saying, “Vasudhaiva Kutumbakam,” which is a Sanskrit phrase found in ancient Hindu texts of India. It means, “The world is one family.”

References

1. Whelan GP, Gary NE, Kostis J, et al. JAMA. 2002;288:1079-84.
2. Pinsky WW. Ann Intern Med. 2017;166:840-1.
3. Educational Commission for Foreign Medical Graduates. IMGs show strong performance in the 2018 Match. March 16, 2018. Available at: https://www.ecfmg.org/news/2018/03/16/imgs-show-strong-performance-in-the-2018-match. Accessed July 20, 2018.
4. National Resident Matching Program. National Resident Matching Program Results and Data: Specialties Matching Service 2015 Appointment Year. Washington, DC; 2015.
5. American Medical Association. Top Specialties for fellowship applicants: 2015 Match at a glance. AMA Wire. October 15, 2015.
6. American Immigration Council. Foreign-Trained Doctors are Critical to Serving Many U.S. Communities. Special Report. January 2018.
7. Educational Commission for Foreign Medical Graduates. 2015 Annual Report. Available at: https://www.ecfmg.org/resources/ECFMG-2015-annual-report.pdf. Accessed July 20, 2018.
8. Tsugawa Y, Jena AB, Orav EJ, et al. BMJ. 2017;356:j273.
9. Begley S. Patients treated by foreign-educated doctors are less likely to die, study finds. STAT. February 2, 2017. Available at: https://www.statnews.com/2017/02/02/foreign-medical-school-graduates. Accessed July 20, 2018.
10. Anderson S. The contributions of immigrants to cancer research in America. National Foundation for American Policy. NFAP Policy Brief. February 2013.
11. Anderson S. Immigrant scientists invaluable to the United States. International Educator. May/June 2015; 4-11.
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13. Thompson MJ, Hagopian A, Fordyce M, et al. J Rural Health. 2009;25:124-34.
14. Nwadiuko J, Varadaraj V, Ranjit A. JAMA. 2018;319:765-6.
15. Stephan PE, Levin SG. Popul Res Policy Rev. 2001;20:59-79.