The COVID-19 pandemic exposed a pressing issue: the U.S. health care system is increasingly dependent on immigrant physicians, but it’s becoming harder for aspiring ones to work and settle in the U.S.
Today, 1 in 4 doctors are foreign-born, international medical graduates. Their numbers are even larger in underserved areas.
This immigrant workforce is key to offsetting a dire physician shortage. The need for more doctors is due, in part, to America’s growing and aging population; U.S.-born doctors’ unwillingness to move to poorer and more rural areas; and U.S.-born doctors’ lack of interest in going into primary care.
As a result, immigrant doctors have become indispensable. But while they’re in demand, more foreign doctors are starting to see the immigration process as risky. Immigrant physicians describe how stricter immigration policies and more competition for residency spots have made the U.S. a less-feasible destination.
In order for immigrant doctors to be licensed to practice in the U.S., they need to complete licensing exams. They also need to obtain clinical experience in the U.S. This can be completed while on a tourist visa or a student visa. However, all immigrant physicians – even if they’re certified specialists in their home country – need to complete a U.S. residency program to practice in the U.S. as specialists.
Nonetheless, a majority of immigrant doctors in the U.S. will complete their American residencies on nonimmigrant visas.
It wasn’t always this way.
There’s a special work visa called the H-1B that allows for both immigrant and nonimmigrant intent. A few decades ago, many immigrant physicians entered residency programs that sponsored H-1B visas, which served as stepping stones to green cards.
But drastic restrictions to the number of people admitted into this visa program, coupled with cuts in graduate medical education funding, have directed most foreign-born doctors to what’s called a J-1 exchange visitors visa.
The J-1 not only prohibits immigration intent, but it also requires that doctors return to their home country for at least two years upon completing residency training.
Foreign-born doctors nonetheless pursue the J-1 because there’s the opportunity to obtain a waiver that will allow them to remain in the U.S. and adjust to an H-1B visa. If selected for the waiver, they must commit to at least three years of service in a medically underserved area in the U.S.
While this system can offer short-term relief to physician shortages, it can also lead to exploitation.
For the duration of the waiver program, immigrant physicians have minimal ability to change employers without violating the conditions of the waiver. Underserved areas are often understaffed and underresourced, which can make for stressful working conditions.
There are financial burdens as well.
International medical graduates often spend tens of thousands of dollars on U.S. medical licensing exams, multiple visa applications, international travel and lodging, residency and green card applications.
They also spend months in unpaid positions in hospital settings to gain the U.S. clinical experience that’s required to apply for residency. Then, to match into residency, immigrant physicians typically need to outperform their American peers on exams. They also need to have more prestigious research qualifications and stronger recommendation letters. Still, immigrant doctors are more likely to match into less-competitive residency programs.
Many international medical graduates will obtain student visas to pursue U.S. graduate degrees in health-related fields before they even start the licensing process. This helps get their foot in the door into a complicated immigration system and build a stronger resume as they prepare for residency applications.
But even those who complete residency won’t necessarily be able to stay in America.
Those with positive experiences from working in underserved communities often struggle to remain in their positions after their waiver contracts are fulfilled because of the green card backlog.
The average immigrant’s wait time for a green card has doubled since the national quota system was introduced in the early 1990s.
Despite frequent calls for change and reform, these bottlenecks continue to adversely affect both patients and doctors.
Work visas have been subject to increasing cuts and restrictions in recent years under both the Trump and Biden administrations. While the U.S. says it wants to attract and retain world-class talent, its byzantine immigration system continually discourages potential hires. The complexity and sheer unwieldiness of the U.S. visa regime are causing the nation to lose skilled professionals to other countries with more streamlined processes.
Selma Hedlund is a postdoctoral associate at the Center of Forced Displacement at Boston University. Distributed by The Conversation and The Associated Press.
