George Abraham, MD, MPH, knows all too well the challenges facing international medical graduates (IMGs). He got his medical degree from the Christian Medical College, in Ludhiana (Punjab), India, where he went on to do his residency and then taught on the faculty for three years. He also did a fellowship in infectious disease and later did an HIV fellowship with the World Health Organization at a time when HIV infections were new to India.
But when he married a Singapore national, who was also a doctor, they found neither of their countries would recognize the other’s credentials.
“It was purely political tit for tat,” Dr. Abraham said, noting that he and his wife then moved to Singapore, where he could only find work below his training. “We decided we had done too much education to drop it all. So we needed to find a third country where both of us could practice.”
During IMG Physicians Recognition Week, Oct. 21–25, the AMA will honor and celebrate the IMG physicians who are a vital component of the physician workforce and the AMA. An Oct. 21 webinar, “Physician Journeys and Contributions in the U. S. Health Care System,” will delve into the unique experiences that shape the careers of this diverse set of physicians, from medical school to clinical practice, highlighting the challenges and triumphs along the way. AMA members can register now.
Immigration is only part of it
The U.S. had its own immigration quirks in the 1990s that he and his wife had to deal with, but the bigger issue was the perception of IMGs in the medical community—something Dr. Abraham encountered after he completed the USMLE and began applying to residency programs.
“Every program I applied to would say, ‘Oh, unfortunately, we have a number of qualified candidates, but you are not one of them. So, sorry, we can't give you a position,’” he said. “This happened so often that I developed what we call’ imposter syndrome’. I thought I must be really bad; otherwise, how was it that I didn't make it into to any of them?”
But there was one Massachusetts internal medicine residency program whose leaders saw through the stigma. Dr. Abraham still works there—at Saint Vincent Hospital, affiliated with the University of Massachusetts Medical School—today, as professor of medicine. He is also the chief of medicine at Saint Vincent Hospital, in Worcester.
“My wife was delivering our first child in Singapore, and I was in Massachusetts interviewing for the position,” he said. “The only question after all the pleasantries and the checking of my medical knowledge was whether they would be willing to waive a year of training.”
At the time, the American Board of Internal Medicine allowed residency programs to waive the third year of training if residents had at least three years of internal medicine experience.
The program’s answer: absolutely.
“I said sign me up,” Dr. Abraham said, adding that the program was just as eager to hire his wife when she applied the following year.
“What struck me from the larger application process was how doors repeatedly closed just because I had trained outside of the United States,” he said. “And even though I had a postgraduate degree—and I was a faculty member at one of the top 10 medical schools in India—that didn't matter, simply because I was an international medical graduate.”
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IMGs add value
That same prejudice exists today in the U.S., but research into IMGs’ effectiveness and value could help chip away at it.
As Dr. Abraham wrote in a recent KevinMD article, “Everyone under the big tent: the international medical graduate,” a 2017 study published in The BMJ in 2017 looked at the quality of care delivered by IMGs and “suggested that after adjustment for disease type, severity and other factors, patients treated by internationally schooled doctors had a slightly, but statistically significant, lower 30-day mortality: 11.2% compared with 11.6% for patients who received care from physicians trained in the U.S.”
“Many IMGs tend to work in rural and medically underserved areas, often to fulfill visa obligations, and this finding indicates that IMGs not only ensure access to care for such populations, but may be more effective because of their unique position,” wrote Dr. Abraham, who is president emeritus of the American College of Physicians.,
Indeed, it is well known that more than half of IMGs practice in underserved areas, well out of proportion to their 25% share of the overall physician workforce.
“That is for two reasons. No. 1, most of the residents who come here to train are coming in on what's called a J-1 Visa, which is an exchange visitor visa that is valid for up to a maximum of seven years,” Dr. Abraham told the AMA. “No. 2, the only way to waive that clause is to work in an area that the Secretary of Health and Human Services has designated as an underserved area. So trainees end up gravitating to the rural areas, primarily because that fulfills the visa-waiver requirement.”
Nevertheless, “several studies have also looked at the challenges of IMGs finding residency positions and demonstrated that IMGs were three times as likely to be selected into a community program as opposed to a university program,” Dr. Abraham wrote, adding that research has shown that “departmental pressure, institutional priority and reputational concerns were cited as factors influencing recruitment of IMGs to university programs.”
From one generation to another
Dr. Abraham has some advice for the younger generation of IMGs. It begins and ends with two things: advocacy and hard work. IMGs need to be in the corridors of Congress to advocate for the profession and demonstrate their talent, he said.
Apart from the visa issues, “You really need to advocate for yourself to say why you're a competitive candidate,” he said. “I always say that if you're not at the table, then you're on the menu.”
But it doesn’t end there.
“Once you're in a position, you need to make yourself into the best candidate ever recruited so that an employer never feels they made a mistake recruiting you,” he said. “You might have to work extra hard compared with that U.S. grad, but that’s OK. That's what we need to do, because that's the way we'll get into the mainstream.”
One of the persistent challenges for IMGs can be thinking they are outsiders and, therefore, not empowered.
“The last thing I always tell people is: Remember, somebody else stuck their neck out to help you get a leg up, to help you get on firm footing and to help you get your career started. Never forget to extend help to someone behind you, because if you don’t, they might never make it,” he said. “We need to pay this forward.”
Learn about the AMA IMG Section, which gives voice to and advocates on issues that impact IMGs. More than 50,000 IMGs are members of the AMA.
