Sonal Chandratre, MD; Aamod Soman, MD
These are unprecedented times, and health care professionals everywhere are doing admirable work to save lives and provide care for patients fighting coronavirus disease (COVID-19). However, for one group of physicians—International Medical Graduates (IMG)—the fight is not limited to COVID-19. In fact, COVID-19 has compounded their existing struggles, and many IMGs find themselves torn between saving lives and complying with existing restrictive immigration policies. IMGs play a vital role in providing health care to many Americans, and as states grapple with surge staffing to fight COVID-19, it is prudent to utilize the existing IMG workforce effectively.
Practice Characteristics of IMGs
An IMG is a physician who graduated from a medical school located outside the United States and Canada.1 Currently, they comprise 25% (n=250,000) of the total active physician population in the United States, including 33% of all primary care physicians;2 and 24% of residents and fellows in ACGME-accredited programs are IMGs.3 IMGs constitute 39% of all internists, 25% of pediatricians, 23% of family physicians, 30% of pulmonologists, 41% of critical care physicians, 21% of anesthesiologists, 51% of geriatricians, 34% of infectious disease pulmonologists, and 30% of psychiatrists—physicians who are directly providing services to COVID-19 patients.2 Furthermore, in New York, New Jersey, and California—the states with maximum COVID-19 impact—the representation of IMGs is twice that of the national average.4 In Wisconsin, IMGs make up 19.3% of the physician workforce.5
What’s more, IMGs constitute 33% of all physicians in areas with the highest poverty rates (where more than 30% of the population lives below the federal poverty level), 42.5% of physicians where per capita income is below $15,000 per year, 36.2% of physicians where 75% or more of the population is nonwhite, and 33% of physicians where 10% or less of the population has a college degree.6 Nearly 21 million (20.8 million) Americans live in areas where more than half of the physicians are IMGs, and nearly 70% of the primary care physicians in these areas are IMGs.7 For example, in Cudahy, Wisconsin, 61% of physicians are IMGs. It’s likely this trend will continue, with the projected shortfall of 61,700 to 94,700 physicians by 2025,7 including many in primary care in underserved and rural areas.6
Challenges for IMGs Posed by COVID-19
IMGs face many challenges that are currently worsened by COVID-19. For example, if they lose their visa status because of layoffs or death, their dependents automatically become illegal, start to accrue unlawful presence, and face deportation. Dependents are unable to seek jobs because of their illegal status, so their only option is to return to their country of origin with their dependent minors, who may be American citizens—something easier said than done.
IMGs on a temporary work visa can work only at the address provided in their approved visa document. This prohibits them from working in any other department or location—even within the same employer system. IMGs working at home also risk noncompliance if they work at any location not previously listed as a worksite in their approved visa document.
IMGs scheduled for a visa extension in the upcoming months face the risk of lapsed status. Typically, one cannot apply for a status extension prior to 6 months from their visa expiration date. With physical distancing measures leading to office closures, there are delays in the processing of extension requests. The government could use the biometric identifiers from an IMGs initial application to extend the current application, but that does not help first-time petitioners who need biometrics. Additionally, even if IMGs could legally still work with a pending application, they cannot drive because their driver’s license is valid only with approved visa status.
An H-1B temporary work visa is issued for 6 years to work in a specialty occupation and, once exhausted, the applicant must leave the United States and reapply after a year. There are several American-trained IMGs with an exhausted H-1B status completely capable of serving in this pandemic. Despite being willing to save lives, they are limited to being silent observers.
In addition, many IMGs who are certified physicians in their country of origin from prestigious hospitals with a vast clinical experience remain without a residency position or are preparing for the 2021 residency process. Despite being trained physicians, they are unable to help with the current crisis, regardless of their clinical capabilities. Meanwhile, there are 4,222 IMGs scheduled to start their residency in July, but with physical distancing implemented in several countries, consulate offices are closed and processing of applications for these incoming physicians is limited.
Possible Strategies to Maximize IMG Contributions During COVID-19
There are several measures that can help maximize IMGs’ participation against COVID-19. COVID-19 should be treated as an extenuating circumstance, and the government should implement temporary authorization for IMGs to work in COVID-19-affected areas without complicating the required paperwork. For example, easy, hassle-free changes in an IMG’s practice location—irrespective of visa status—would help an IMG immediately serve in COVID-19 hot spot areas. The fastest way to do this is to approve existing pending permanent residency applications. United Kingdom immigration has announced free automatic 1-year visa extensions for health care workers whose visas are expiring in October 2020.8 The United States also should allow automatic extensions of employment authorization extension applications for all immigrant health care workers.
For incoming IMGs scheduled to start their residency in July 2020, the government should take measures to promptly process visa applications. Consular offices overseas should interview these IMGs on a virtual platform or, if not feasible, they should waive that requirement temporarily.
As already initiated in the state of New York,9 states anticipating their COVID-19 surge should preemptively issue an executive order that temporarily allows IMGs with 1 year of American clinical experience to join the workforce. The government should give temporary permits to work in COVID-19 areas to IMGs with completed licensure exams and adequate overseas clinical expertise equivalent to American training. American-trained IMGs with exhausted 6-year visas should be given temporary licenses to serve in COVID-19 areas.
In summary, IMGs are pleading desperately with American policymakers to decrease visa restrictions to bolster their ability to contribute during the COVID-19 pandemic. IMGs are dedicated to serving American patients and to their solemnity in being true to the Hippocratic Oath they once took. It may be illegal to stay in a country, but saving lives should not become illegal.
- Certification – Definition of an IMG. Educational Commission for Foreign Medical Graduates. Updated August 27, 2019. Accessed April 9, 2020. https://www.ecfmg.org/certification/definition-img.html
- Active Physicians Who Are International Medical Graduates (IMGs) by Specialty, 2017. Association of American Medical Colleges. April 1, 2020. Accessed May 8, 2020. https://www.aamc.org/data-reports/workforce/interactive-data/active-physicians-who-are-international-medical-graduates-imgs-specialty-2017
- 2018 Physician Specialty Data Report. Executive Summary. Association of American Medical Colleges. Accessed February 11, 2020. https://www.aamc.org/system/files/2019-08/2018executivesummary.pdf
- Harris P. Doctors will beat COVID-19. Let’s bring more of them to the fight. American Medical Association. Accessed May 8, 2020. https://www.ama-assn.org/about/leadership/doctors-will-beat-covid-19-let-s-bring-more-them-fight
- Wisconsin Physician Workforce Profile. Association of American Medical Colleges. Accessed May 8, 2020. https://www.aamc.org/system/files/2019-12/state-physician-Wisconsin-2019%5B1%5D.pdf
- Foreign-Trained Doctors are Critical to Serving Many U.S. Communities. American Immigration Council. Published January 17, 2018. Accessed May 8, 2020. https://www.americanimmigrationcouncil.org/research/foreign-trained-doctors-are-critical-serving-many-us-communities
- Mann S. AMC Research Confirms Looming Physician Shortage. Association of American Medical Colleges. September 27, 2016. Accessed May 8, 2020. https://www.aamc.org/news-insights/aamc-research-confirms-looming-physician-shortage
- Coronavirus (COVID-19): advice for UK visa applicants and temporary UK residents. GOV.UK. Published March 24, 2020. Accessed April 9, 2020. https://www.gov.uk/guidance/coronavirus-covid-19-advice-for-uk-visa-applicants-and-temporary-uk-residents
- COVID-19 Pandemic and Professional Practice. Important Information for Licensees Impacted by COVID-19. Office of the Professions. New York State Education Department. Accessed April 10, 2020. http://www.op.nysed.gov/COVID-19_EO.html