By Apoorve Nayyar, MD
International medical graduates (IMGs) form a diverse cohort of the US physician workforce. Historically, IMGs have played a pivotal role in meeting the needs of an ever expanding physician shortage in the United States. According to a recent analysis by the Migration Policy Institute, in 2018, IMGs constituted 28% of the total number of practicing physicians in the United States. In addition to bridging the gap for physician shortage, IMGs also bring diverse perspectives from all parts of the world contributing to the melting pot of cultures that is America. However, given the increasing visa restrictions and limitations on the number of training spots available, the path for IMGs to match into surgical specialties can be challenging and filled with periods of uncertainty.
Similarly, for programs previously unfamiliar with matching IMGs, the logistics of hiring and training IMGs can be confusing. In order to be eligible to participate in the Match process, IMGs are required to be certified by the Educational Commission of Foreign Medical Graduates (ECFMG) which requires successful completion of USMLE Step 1, Step 2 CS and Step 2 CK, in addition to successful graduation from their medical schools. Once ECFMG certified, the IMGs are eligible to participate in ERAS and NRMP to find the right residency position for them, just like any American medical school student/graduate applying for residency. Non-US citizens also require some form of visa sponsorship in order to participate in the training program. The most commonly available sponsorship options include either the J1 or the H1B visa, depending on individual life situations and institutional policy. The J1 visa allows the candidates to participate in their respective training programs for up to a total of 7 years; however this may be extended by 1-2 years under special circumstances and/or further training. The 7 year time limit, however, may preclude some candidates from taking dedicated research/academic time during residency. General surgery has historically been a more difficult specialty for IMGs to secure a position in, with many successful candidates completing a preliminary year before securing a categorical position. In the 2020 Match, IMGs accounted for 2.4% of all the categorical surgical positions filled.
Surgery is an extremely competitive field; in addition to candidates being eligible, most programs work hard to identify the “best” candidates for their program, candidates that they believe will thrive and succeed in their training program. In that setting it can indeed be difficult to ascertain the competency and preparedness of IMGs, given the variability of prior educational experiences. A holistic review of the candidates’ application including objective (USMLE scores, medical school academic performance, research experiences/publications) and subjective evidence (letters of recommendation, personal statement, prior clinical experience in the US) can provide programs with critical information for resident selection. While it is of paramount importance to assess the competency of all applicants, it is equally important to not let that turn into bias or discrimination towards IMGs. Multiple studies have shed light on the existence of a negative bias towards IMGs, despite no evidence of a difference in surgical outcomes or performance during residency between IMGs and US medical graduates. This bias can range from subtle microaggressions during interviews to overt hostility and discrimination. I distinctly remember a conversation with a faculty member during an interview “Apoorve, you know the problem with IMGs is that we don’t really know who you are, where you come from, or whether you will be able to communicate with our patients in English. We tend to prefer candidates that we know will assimilate well culturally”. I remember feeling shocked and shattered coming out of that interview questioning my self-worth. It made me feel like everything I had done in my life up till that moment did not matter, and the only thing that mattered was where I am from.
While conversations like these aren’t uncommon, they are definitely not representative of the vast majority of the surgeons that I have come across, who are not only warm and welcoming but genuinely interested in helping you achieve your career goals. You want to be at a place where you are celebrated, not just tolerated. I am so grateful that despite being an outsider to the world of American surgery, I have been fortunate to have found my tribe of mentors and friends who not only inspire me to be an excellent surgeon, but to be a better human being everyday. The kindness that I have experienced from them is unmatched and I only hope I can pay it forward to the next generation of budding surgeons.
Given its challenges, the question that’s most often posed to IMGs is why would one want to go through all that? Why not just train and practice in your home country? While everyone has their own reasons, for me it was the ability to learn and practice most cutting-edge evidence based medicine with a hope to make a bigger impact. Most IMGs I have known tend to be driven in pursuit of better opportunities, better futures for themselves and for a better world. It is indeed a big sacrifice, to move away from your family and friends, not knowing when you will get to see them again. This has been exacerbated significantly with the ongoing COVID-19 pandemic with travel restrictions and not being able to be there for your family. So if you know or work with an IMG, show them kindness, it will be much appreciated.
My advice for IMG applicants? Work hard, trust your mentors, constantly seek to improve yourself, ask for actionable feedback, be open minded to opportunities and have faith in the process. The road to surgical residency for IMGs is long and hard, but with hard work, grit, and resiliency, nothing is impossible.
Apoorve Nayyar, MD (@apoorvenayyar) is currently a second-year general surgery resident at the University of Iowa Hospitals and Clinics (UIowa_Surgery). He grew up in Amritsar, India and completed his medical school in Mumbai, India before coming to the US for further training. Dr. Nayyar aspires to be a surgical oncologist with a research focus on disparities in cancer care and intersectional equity in healthcare.
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