By Zaid Abdel-Rahman, MD

“We shall not cease from exploration

And the end of all our exploring

Will be to arrive where we started

And know the place for the first time.”

—T.S. Eliot, “Little Gidding”

During my final years of medical school, Amman, Jordan, was a vibrant city. It had a blooming art scene, endless concerts that sold out months in advance, modern local artists jamming in 2,000-year-old Roman theatres, breathtaking summer nights, and busy streets until the early morning hours.

That was when I met Hanan. I was a third-year medical student, while she was about to start her first job as an industrial engineer. I was mostly thinking about medicine. She was thinking about life. We loved Amman (still do). We had our families around us and a phenomenal group of friends that we are still very close to today. Local training opportunities after medical school were not great, but other things made up for that. My point is (and we realize how lucky we are to be able to say this) that when we decided to move across the globe in 2013, we were not running away as much as we were looking for something better.

On June 10, 2015, I entered the United States on a J-1 visa to start internal medicine residency at Henry Ford Hospital in Detroit. I crashed at peoples’ houses for the first month and a half of my internship, because my apartment was not ready. I could not get a car for the first few months because I had no credit score, so I mostly walked. Internship was a steep learning curve for obvious reasons. My first few months were not pleasant. I regretted my decision to come to the U.S. and even called several hospitals back in Jordan to see if I could still get a residency spot, but it was too late. Hanan joined me 10 months later. She was welcomed by a friend who told her that was the first time she saw me smile. I immediately bounced back. Detroit became our new home. We made friends for life. We had a family again. Towards the end of residency, another member joined that family, a beautiful 7.5-lb baby boy—we named him Ghassan, an Arabic name that means “youthful.”

Throughout my residency, Hanan continued to work remotely with her company. When I matched into the hematology/oncology fellowship program at Mayo Clinic in Jacksonville, FL, she was accepted into the data analytics master’s program at the Georgia Institute of Technology (#GoJackets).

I had a great mentor who guided me through fellowship and fostered my interest in myeloid disorders. Three years, a pandemic, and an ASCO Young Investigator Award later, I accepted a position for an advanced fellowship in stem cell transplantation and cellular therapies at the University of Texas MD Anderson Cancer Center. Hanan continued to work while studying for her master’s degree, and soon after her graduation she landed her dream job at a very reputable company. Then it was my turn. We had to decide about my job in 2020, the year of the unprecedented cascading collective traumas to humanity. It was also the year that marked the third anniversary of my last visit to my family in Amman, initially because of visa issues and later because of COVID-19 travel restrictions.

I agonized over the decision to stay in the U.S. when my training concludes. This is one of the hardest choices I have ever had to make. To everyone around me, I may have seemed at ease with the decision, but it was a struggle when it should have been driven by excitement, ambition, and passion for what I want to do. My thoughts were being saturated with apprehension over changing immigration laws and bureaucracy.

Given our visa statuses, these were our options:

1. Go back to Amman permanently.
2. Work on an O-1 visa. O-1 is a non-immigrant visa for individuals with “extraordinary abilities.” I do not consider myself extraordinary in any way, but my lawyer assured me that physicians with advanced training routinely qualify without issues!
3. Work on a J-1 waiver. J-1 visas come with a requirement of returning home after training unless the physician agrees to work in a designated “health care professional shortage area” or a “medically underserved area” for 3 years. This option would significantly restrict the places where I could work, as the waiver is available in only a few locations around the country with further limitations of available institutions able to treat patients with myeloid disorders and offer stem cell transplantation (my specialty). I do not oppose the requirement—working in an underserved area for 3 years in exchange for the training I received feels like the least I can do—but it comes with a caveat that I will talk about below.

Hanan and I felt that we still had something to achieve and experience in this country. So, option 1 was set aside for a while. The other two options might seem different, but they had one thing in common that was so powerful to the point where they essentially became the same option: They both meant that Hanan, the successful data analyst who had just found her dream job, would be forced to quit once I was no longer a trainee.

Spouses of O-1 visa holders (option 2) are given O-3 visas and are not allowed to work. At all! For life! So, this was not an option anymore. As for option 3, I would switch to an H-1B alien status, and Hanan to H-4 status. H-4 work permits have always been a matter of ferocious political debate. In 2015, the Obama administration passed a rule that gave H-4 visa holders the right to work in any field if their spouses had an approved immigrant worker petition (i.e., be on track for green card processing). In 2017, the Trump administration proposed a ban on the H-4 work permit rule. This ban would have had a devastating financial and psychological toll on tens of thousands of workers (mostly women and mostly Indians). Fortunately, the Biden administration revoked the legislation to ban the rule. Despite this seemingly positive change, the H-4 work permit application process was buried under a mountain of bureaucratic procedures that were only made worse by COVID-19.

While my switch to H-1B status takes as little as a few weeks, Hanan’s switch to H-4 status can take up to 24 months to finalize. This process is so lengthy and complex to the point where it is mathematically guaranteed that the H-4 holder will lose their job (this is a recurring theme for renewals as well, not just for the initial application).^1,2 Other external factors also play a major role here; hospitals’ immigration attorneys sometimes delay initiating the immigrant worker petition for various reasons, which subsequently delays the employment of the physician’s spouse even further. During this period, physician spouses are forced to quit their job and remain unemployed.

I looked at this from all possible angles, and I could only see one thing: Hanan’s career is taking yet another hit, but this time it was not for the extra hours I spend at work or the constant moving from one city to another for training. This time, she has to make a career sacrifice because I chose to stay here in the United States and serve in an area of need.

Suddenly, going back to Amman does not seem unreasonable anymore. We also understand that the “brain drain” in Jordan is real.³ Our friends and colleagues constantly remind us of the advantages of staying here (which we acknowledge), but often dismiss the downsides. We look back at the time when we decided to move across the globe and try to define the boundaries of the “better option” that we came here for. We ask ourselves, is it worth it? Is it an expectation for international physicians’ spouses not to work? Are we needed in these underserved areas? And if we are, why are our spouses forced to quit their jobs and put their lives and careers on hold for several years?

Dr. Abdel-Rahman is a stem cell transplantation and cellular therapies fellow at the University of Texas MD Anderson Cancer Center and a member of the ASCO Trainee and Early Career Council.
Follow him on Twitter @ZaidAR_MD. Disclosure.

References

1. US Citizenship and Immigration Services. USCIS Temporarily Suspends Biometrics Requirement for Certain Form I-539 Applicants. Reviewed/updated May 13, 2021. Accessed Aug 19, 2021.
2. Anderson S. USCIS Taking Two Years To Process Many Applications For H-1B Spouses. Forbes. Feb 9, 2021.
3. Abdel-Razeq H, Barbar M, Shamieh O, et al. Oncology Medical Training and Practice: Managing Jordan’s Brain Drain Through Brain Train—The King Hussein Cancer Center Experience. JCO Global Oncology. 2020:1041-5.