Challenges facing international medical graduates (IMGs) during COVID-19

Watch the AMA's daily COVID-19 update, with insights from AMA leaders and experts about the pandemic.

AMA Chief Experience Officer Todd Unger speaks with President and CEO of ECFMG William Pinsky, MD, AMA Vice President of GME Innovations John Andrews, MD, and psychiatrist and international medical graduate (IMG) Kamalika Roy, MD, on updates regarding COVID-19 including the challenges facing International Medical Graduates during the COVID-19 pandemic.

Learn more at the AMA COVID-19 resource center.

Unger: Hello. This is the American Medical Association's COVID-19 update. Today we're looking at the challenges facing international medical graduates during the COVID-19 pandemic. I'm joined today by Dr. William Pinsky, president and CEO of the Educational Commission for Foreign Medical Graduates or ECFMG in Philadelphia, Dr. John Andrews, AMA's vice president of graduate medical education innovations in Chicago, and Dr. Kamalika Roy, an IMG and assistant professor in the Department of Psychiatry at the Oregon Health and Science University in Portland, Oregon. I'm Todd Unger, AMA's chief experience officer in Chicago.

Dr Pinsky, I'd like you to start with a little bit of background on the importance of IMGs to medical care in the United States.

Dr. Pinsky: Sure, Todd. Thanks and thanks for inviting me today. Hello, John and Kamalika. Nice to see you this morning as well. International medical graduates have been very important to health care delivery in the United States for decades. ECFMG was formed almost 70 years ago in order to be able to certify international medical graduates, their education, and their background. According to the AMA database, approximately 25% of all physicians in the United States are international medical graduates. These individuals generally are among the brightest around because it is a pretty strenuous journey to come through the process and be qualified to practice here. International medical graduates frequently are more likely to be practicing in underserved areas as well, including primary care specialties.

So from an access perspective in the United States for quality health care, they're extremely important, and it's reflected in the training programs as well because approximately 25% of residents and fellows in training are international medical graduates.

Unger: Is there any news or impact in the Trump administration's announcement recently about a 60-day halt on green cards?

Dr. Pinsky: Another good question and obvious concern all around. Any time there's a change in immigration policy, whether it's an executive order or something else, it's a concern. Fortunately, we have had a longstanding excellent relationship with the Department of State. They are excellent partners with us, and they have been very responsive to us during this administration as various changes have occurred, and then over the last couple of months with the announcement of closing of the embassies and the consulates in terms of processing visas, they've responded to us almost immediately and have been facilitating the process of visas at the consulate and embassy level.

The most recent executive order that has come out was immediately clarified by our colleagues in State that the reference is to immigration visas. The international medical graduates, particularly those on the J1 visas that we work with, do not come here on an immigration visa. And even on top of that, essential personnel such as health care workers, in particular physicians, have been excluded from that. So even though we all had a little bit of a scare the other day, fortunately because we have good advocates in the Department of State, it's turning out the proper way.

Unger: Well, that is good news. Dr. Roy, can you tell us a little bit in your view what the most challenging issues are for IMGs as a result of the pandemic?

Dr. Roy: So there are several challenges for IMGs in terms of temporary work visa and immigration before the pandemic. What this pandemic did is actually made it worse and made it more unstable. Talking about the executive order, the recent new executive order at all because that did not change much in terms of our challenges.

However, the pandemic itself, the closing, the slowing down of processes by the USCIS and the Department of State everywhere, that actually caused a lot of challenges in terms of renewing the existing visas. The IMGs that are already working here for many years, most of them are on H1B visa. They are not on J1, so I just want to clarify I'm not talking about the J1 visa that Dr. Pinsky just mentioned. So that process is a separate problem, but then the IMG doctors that are already working here, they work on H1B visa and they have to keep on renewing that H1B visa every few years. Sometimes it's one year, sometimes it's two or three years, whatever the contract says, depending on that.

So that process has been halted, and it's a multilayer problem. It's not only USCIS. Before the application goes into USCIS, there are several steps that has to come from the Department of Labor and then internally from the institutions. So there are several steps that takes many months to begin with. With this pandemic, everything getting halted, everything being slower than before, it has caused a significant challenge in terms of maintaining employment or changing one employment from another one.

So realistically what it comes down to, I know there is a grace period of 60 days and everything else, but realistically, if an IMG during this pandemic loses a job or is furloughed for some reason or becomes sick or cannot work for any reason, then realistically, it's impossible to find another job, go through the paperwork, credentialing, licensing and every other thing within that short period of time against that delay that's already happening from the administration to secure another job. So practically, they're at a very high risk of losing their legal status, and their family also are at the same risk of losing their legal status.

Unger: Dr. Pinsky, Dr. Andrews, any comments on that?

Dr. Pinsky: The only comment I would make, and Kamalika, I think, did a excellent job in describing the stress that international medical graduates have on top of everything else going on, the one thing I would add is the Department of State in their working with USCIS have asked to direct people to the expedited review process. So if one goes into the website, to the expedited review link, there is an opportunity to get some acceleration of the process. Typically, in a non-pandemic time, and Kamalika you can correct me if I'm wrong, in a non-pandemic time, it's a pretty long process itself. But now, I believe anyway, that they are attempting to expedite it through that website, and so we would direct people to go there.

Unger: Dr. Andrews, maybe you could speak to some of the resources and advocacy we've been working on with the ECFMG to assist and provide guidance to IMGs at this time.

Dr. Andrews: I might just add one point, before I do, on some of the comments that doctors Pinsky and Roy have made. We talked about the stresses in this situation that IMGs are experiencing and given my responsibility for graduate medical education, those stresses are compounded for many of our trainees. They face the same issues, but because the training programs that they're in and the timeframes that they're on, the stress is compressed. And so things like visa deadlines and delays in processing of visas, concern about the ability to extend visas if training is extended are particularly anxiety provoking for international and local graduates who are in residency training programs. So I think it's worth noting that.

We've been cooperating with ECFMG and other organizations to make sure the Department of State understands these issues, to make sure that unnecessary barriers to processing of visas aren't are put up. And furthermore, we're asking for consideration of some of the requirements that underpin visas to allow more latitude for international medical graduates to practice and address the needs during the pandemic. So Dr. Roy could probably speak to the restrictions on H1B visa holders, for example, in their employment relationships. We're asking for some relaxation of those requirements so that the sites at which international medical graduates practice can be more varied and can meet the need in responding to the pandemic.

Dr. Roy: I agree with that. So on H1B visa we can work only one site, the site that's mentioned in our initial application. For example, I work in inpatient setting and some of our care changed to tele-visits and I had to go another extra step of informing the Department of Labor with a new work site, which was my home. So every thing that we add, even a telehealth visit, actually adds up to a lot of paperwork.

I also wanted to mention, many of the IMG physicians formally trained with master's degree or even higher degree in public health, and in this situation they are actually one of the more expert people that can help with the public health aspect of this pandemic. And we are unable to do that because of this work site restriction because we are still supposed to work in only one place, and we cannot even provide any telehealth out of the state or out of our work site.

That restriction comes from a protective standpoint so that nobody is exploited for being an IMG. I totally understand that, but with this pandemic probably some exceptions will be more helpful for the communities that we serve.

Unger: Does anyone have any final words of guidance for those in the IMG community about how to navigate this time successfully?

Dr. Andrews: Well, I would just reassure people that organizations like ECFMG and the AMA are thinking about the interests of IMGs and to the degree that we're able, we're trying to make resources available. So Todd, I know you'll provide some links to resources that the AMA is promoting. I know there are great resources on ECFMG's website that answer a lot of the questions that we've attempted to address in this webinar today and so I hope that people will take advantage of those resources and understand the situation better as a good use for them.

Dr. Pinsky: The one thing I would add, thank you John for that, is that AMA along with ECFMG are members of the Coalition for Physician Accountability, which are the major, I guess house of medicine type organizations in the country, and we are really united as a coalition, and in fact have four work groups that we're participating in right now. I think John, you probably chair one of those or co-chair one of those and so there really is a concerted effort, a unified effort behind us.

Dr. Roy: I would like to mention, AMA has long been an advocate for IMGs. I would say probably the only organization that truly advocates for all IMGs. In 2018, AMA sent out a letter to the USCIS requesting to grant permanent legal status for all IMG doctors. And I think this is the time, this pandemic, this crisis is the time that AMA follows up on that letter and probably sends out another emergency letter to the vice president to the White House Task Force for Coronavirus, to consider this matter again to grant permanent status for all the IMGs at least to the IMGs that are working in the rural and underserved area.

I'm a little bit concerned that these people, in this immigration and administrative processes, this rural and underserved, the critical access hospitals might lose their only doctors that they got after many years of search. So looking at that realistic risk, looking at that possibility, I think it's worth a try for AMA to request, to follow up on the same thing that they asked a couple of years ago.

Unger: Dr Pinsky, Dr. Andrews, any final comments?

Dr. Pinsky: No, I just appreciate the opportunity today to be able to discuss this with my colleagues. I appreciate the AMAs support. We've long been a supporter of the IMG section in the AMA, and since I've been in my position the last four years, I've been very active there. So I know that there's great passion within the IMG section and we've been very pleased to be able to advocate along with the AMA.

Unger: Yes, well thank you, Dr. Pinsky and the ECFMG for your continued support and advocacy for IMGs. Dr. Roy, Dr. Andrews, thanks very much for being with us today. That's it for today's COVID-19 update.

For resources for IMGs, please go to the COVID resource center on the AMA's site at ama-assn.org/COVID-19.

Stay safe this weekend. We'll be back next week with another set of COVID-19 updates.

Disclaimer: The viewpoints expressed in this video are those of the participants and/or do not necessarily reflect the views and policies of the AMA.