International medical graduates (IMGs) play an important role in the US healthcare delivery system. About a quarter of the 800,000 practicing physicians are IMGs, and 41% of practicing IMGs are in primary care disciplines (1). These physicians play a vital role in the care of vulnerable populations in the underserved areas of both urban and rural settings. In a survey conducted in pediatrics, international IMGs are more likely to work in underserved areas than are American medical school graduates (2).
About 18% of graduating pediatric residents are IMGs, and about 25% of fellows are IMGs (3). About 40% and 42% of internal medicine residents and fellows, respectively, are IMGs, and at least two-thirds of them are dependent on visas (4). The most common type of visa used by IMGs to participate in US medical programs is the J1 visa. Other types of visas are H1B and J2.
Limiting the number of working personnel in many government offices, including the US Citizenship and Immigration Services (USCIS), will affect the processing of visas for graduating physicians, residents, and fellows, potentially leaving them unemployed for a few months after graduation, which is usually June 30, 2020.
What does this mean for healthcare?
Inasmuch as approximately 20% to 30% of graduating physicians are dependent on visas, and most trainees with J1 visas will take jobs in underserved areas, delays in visa processing can have a significant impact on the healthcare delivery system. With graduating fellows and residents being unemployed for the first few months of the academic year, starting in July 2020, the number of physicians will decrease, particularly in underserved areas with physician shortages. The front line physicians during the COVID-19 pandemic are internists, critical care physicians, nephrologists, and primary care physicians, to mention a few, and the great majority of IMGs belong to these physician groups.
With fewer physicians available to practice, patients’ waiting times may increase, and that can jeopardize their health. Fewer physicians could also mean patients must travel longer distances than usual to seek medical care, which is an additio°nal burden. The number of people visiting emergency rooms will increase further as patients may try to wait out worrisome medical problems. Overburdened emergency rooms can result in more waste of resources and compromised medical care. Also, emergency rooms will increase the exposure of patients and staff to contagious disease, creating a vicious cycle. Overloading the healthcare system will lead to stress and burnout and can potentially add to this cycle.
What does this mean for physicians?
One of my friends said, “Perhaps this delay is a month or two. The problem is no pay and no driver’s license during those months, but other than that we should be OK.” Is it that simple, or are we falsely reassuring ourselves to get our lives moving?
Trainees who complete their training will have a grace period of 30 days before traveling to depart the country, during which time the person is not using any visa but is under the jurisdiction of the USCIS (6). Also, it is legal to stay in the United States as long as one has applied for a valid visa and it has not been rejected. If a trainee is scheduled for a board examination, the visa can be extended for up to 6 months (7).
Even though one can stay in the United States legally, one is not allowed to work, which translates to no pay. Most IMGs do not have family in the United States, and they cannot go home because, when one leaves the United States when a visa is in process, all the submitted paperwork is nullified, and one has to start everything from scratch amid the closure of many embassies in their respective foreign countries. Imagine the time and expense that go into this process, particularly when one is unemployed!
What about the mental and physical well-being of these physicians, who have just served the country on the front lines during this pandemic? Some may even be recovering from COVID-19. Additionally, working for long hours in close proximity to sick patients—and the inability to completely prevent negative patient outcomes—can cause a significant emotional drain. And what about physician burnout? Not having a family close by and the inability to visit loved ones can only worsen these physicians’ physical and mental health (Figure 1).
Compromised physician well-being amid stressors due to COVID-19
Citation: Kidney News 12, 6
Moreover, when visas are finally approved, these physicians now have the pressure of adjusting to new job environments. This, again, is a great stressor even in the best of circumstances. If children are added to this equation (which applies to about 40% of pediatric IMGs) (8), it is utterly incomprehensible.
Not the least, our inability to help our patients when they are in a dire situation can cause substantial guilt.
Is there a possible solution?
There is no standard solution. But because all these issues stem from the visa/change of status situation, focusing on this one issue could help fix all the associated problems. Inasmuch as premium processing (which usually is done within 15 days) is on hold at this time, and regular visa processing requires at least 3 to 12 months and can be further delayed amid the pandemic, solving this problem could potentially mitigate all the issues faced by both patients and physicians.
The USCIS could consider allowing expedited processing for physician visas. Nonprofit organizations like the Education Commission for Foreign Medical Graduates and the Exchange Visitor Sponsorship Program can petition the USCIS for expedited processing. Associations of immigration lawyers who work closely with physicians can help authorities understand the need for physicians during this dire situation. Hospital administrations can meet with senators and members of Congress and seek their help. We physicians can write to or speak with government representatives as well.
With these few thoughts, I would like to conclude by saying, we are all in this together—and stay safe, dear friends.
Acknowledgment
The author thanks Dipankar Gupta, MD, for reviewing this article.
