Immigrant physicians and international medical graduates (IMGs) have for decades been very important to the healthcare delivery in the United States. For many currently serving on the front lines, the path has been full of challenges and uncertainties, now acutely worsened by the pandemic at hand. Manpreet Malik, MD, is one of those hospitalists. He grew up in a small city in India. He completed medical school in South India where he met students from all over the world and learned to speak a new language to serve local patients. The multicultural experience inspired him to pursue residency in the United States. Manpreet obtained a J-1 visa for residency and subsequently applied for a J-1 waiver for his first hospitalist job in 2013. Then his employer, a nonprofit organization, applied for H-1B and permanent resident status. He continues on an H-1B status but awaits his green card 7 years later. His wife, a dentist, is also an H-1B visa holder and they have two children. While they have assimilated into American society and flourished professionally, a sense of security eludes them. The COVID-19 pandemic has amplified this for their family. Like many other families, they are both in high-risk occupations and worry about the future, including what would happen if either or both of them contracted the virus. Their carefully planned life feels like a wobbly house of cards.
Immigrant healthcare workers are on the front lines in the fight against COVID-19 in the United States, accounting for 16.4% of healthcare workers amid this pandemic.1 Of physicians in the United States, 29% are not born in the United States,and of the practicing hospitalists, 32% are IMGs.1,2 IMGs are physicians who have graduated from medical schools outside of the United States and Canada who lack accreditation by the Liaison Committee on Medical Education.3 IMGs are a heterogeneous group with widely varying cultural, educational, and linguistic backgrounds with around 12,000 IMGs applying yearly for US residency positions.4 IMG hospitalists are uniquely positioned at the front lines facing arguably more risks with less recognition.5 The top five countries sending physicians to the United States are India, China, the Philippines, South Korea, and Pakistan.6 Yet many of these doctors—more than a third of those practicing in this country who graduated from international medical schools—have visa restrictions that limit their ability to work in communities with the greatest need.7 Another group of approximately 65,000 IMGs currently living in the United States are not licensed; they have not passed the board exam because they haven’t matched into a residency program to be eligible to take it.8 Many are working other jobs such as medical research, even though they could be deployed to serve as scribes or work in triage via telemedicine if their visas permitted.
During the COVID-19 pandemic, immigrant doctors are putting their lives on the line daily to care for patients. Immigrant doctors on visas are not eligible for Medicaid or Social Security benefits. Further, their partners and children are often dependent on them for legal resident status in the United States because of employer-based visa sponsorship. As the primary visa holder, if a non–US-born physician in the United States gets severely ill while fighting the virus, or gets disabled, they may have no benefits to fall back on. These physicians have houses, families, and children who are American citizens, and they are contributing members of society. Physicians on visas pay taxes the same way US citizens do. If their health or employment is jeopardized, their families would be unable to stay in the US legally, becoming undocumented and risking deportation. These physicians, who are fighting COVID-19 today, are helpless to provide a stable structure for their own loved ones.
With the COVID-19 pandemic unfolding, there is a risk of more physician shortages. The US healthcare workforce relies on immigrant physicians to help provide high-quality and accessible patient care. There are challenges for IMGs for getting into residency programs, and this limits the potential workforce during COVID-19. This year, according to the National Resident Matching Program, 4,222 non–US-born IMGs are due to start their US residency training on July 1.9 These doctors have the opportunity to serve across the country during this pandemic. According to data from the matching program, IMGs make up a large proportion of the workforce, obtaining 23% of the total number of US residency positions filled, and are in many leading academic institutions. These doctors, many of whom are waiting for their visas to be processed, need to be admitted in order to provide the care that Americans need during this pandemic. A similar number of IMGs will be completing their specialty training and are due to become attending physicians in their chosen field, including areas with critical shortages in this pandemic, such as critical care medicine. These skilled physicians depend on the processing of visa extensions or green cards in order to remain in the United States. Subspecialties like internal medicine and family medicine have a large proportion of actively practicing IMGs,7 and therefore provide primary care and inpatient care across the nation, especially in underserved areas. However, the geographic location of their practice is limited to the place that sponsored their visa. So a physician in rural Minnesota, where the outbreak of COVID-19 is not severe, cannot travel to hot spots such as New York or Detroit to provide care, even if they have a desire to serve.
For IMGs, the process of obtaining legal status in the US and pertinent immigration policies includes utilizing the H-1B visa program for highly skilled workers10 or J-1 visas for residencies.11 H-1B visas are usually granted for sponsored positions in underserved or rural areas for at least 3 years, and the healthcare sector must compete with other industries, such as tech, engineering, and other specialty occupations. Physicians working on H-1B visas may apply for permanent work permits, though there is an annual cap for each country and candidates may wait decades to receive one. As a J-1 visa (cultural exchange program) holder, physicians are required to practice in their home country for 2 years prior to working again in the United States. This requirement could be waived by turning to the Conrad 30 Waiver Program12 or J-1 waivers if they agreed to work in an underserved area in the United States. A limited number of J-1 waivers for each state are dispensed on a first-come, first-served basis (30 IMGs per state per year). This program currently is only authorized through the end of 2020, although legislation has been introduced to extend it, which could expand the slots.13 Applying for a J-1 waiver thus becomes a race against time with high-stakes suspense and anxiety for many IMGs. Most, regardless of visa status, dream of a stable and secure life, with permanent resident status as they serve their communities. For some, however, the endgame could mean deportation and the premature demise of dreams.
Permanent resident status is allotted by country, and there is a long wait for green cards. Three-quarters of skilled workers waiting for green cards are from India. That translates to more than 700,000 people, of which approximately 200,000 are expected to die of old age before being granted green cards.14,15 In the meantime, while they live with restrictions on both their employment and mobility, many physicians are doing essential medical work in underserved and rural areas throughout the United States.
We urge immigration reform to increase the physician workforce by providing immigrant doctors and IMGs with more flexibility to travel to areas where they are needed the most during this pandemic. There should be a blanket extension of visa deadlines. IMGs on J-1 student visas and H-1B specialty work visas should be exempt from any future immigration bans or limitations during the COVID-19 pandemic. The time is right for accelerating permanent resident status for these highly skilled IMGs. Green cards soon after finishing residency or fellowship training or satisfying a condition of initial visa approval should be the norm instead of a stressful unending wait. Clinicians who serve in underserved communities should be incentivized, and this should include health benefits. Restrictions related to primary and secondary work sites, as well as number of J-1 waivers, should also be relaxed. This flexibility would allow immigrant physicians to care at a variety of locations or by means of telemedicine.
A physician’s role is to heal and to serve their patients, regardless of their own origin. We are the voices of America’s immigrant physicians, particularly hospitalists, serving as frontline workers in our nation’s response to the COVID-19 crisis. The battle against COVID-19 has strained many of our resources, including the need for physicians. Uncertainty and chaos reign professionally and personally for many healthcare workers across America, and more challenges lie ahead for the foreseeable future. Healthcare workers are the unselfish and unwavering wall that stands between COVID-19 and more lives lost in our country. Every effort should be made to preserve and strengthen the healthcare workforce. Immigrant hospitalists, shackled by visa restrictions, could play an even bigger role if their obstacles were removed. It is time to provide them with the sense of security they deserve and rebuild the house of cards into something with a stronger foundation and more stability for our future.
The authors have no potential conflict of interest to disclose.