In Lebanon, where Antoine Beayno, MD, grew up and went to medical school, homosexuality is illegal. LGBTQ+ people can be fired, blackmailed, or arrested. They sometimes are even refused medical care, says Beayno, who has long been concerned about the health of this persecuted community.
So Beayno, now a second-year psychiatry resident at Mount Sinai Morningside/West in Manhattan, set his sights on coming to the United States, where he could practice medicine in LGBTQ+, HIV, and transgender clinics.
Even while working grueling hours as a resident back in Lebanon, Beayno started plowing his way through a mass of requirements and recommendations — an English-language test, U.S. medical licensing exams, and more — to gain the residency slot that all international physicians need if they want to practice medicine in the United States.
Throughout, Beayno worried whether he would be among the select cadre who make it through the competitive U.S. residency application process — and then get the requisite visa.
But Beayno regrets none of it.
“Sometimes I pinch myself and think ‘Am I really here?’” he says. “There just are no opportunities like this back home. I’m learning and contributing more than I had even hoped.”
Beayno is part of a U.S. workforce that is often seen but little understood: foreign-born and -educated doctors who come to the United States for residency and, in many cases, stay long-term.
Consider some statistics: In 2021, approximately 1 in 5 active U.S. physicians were born and attended medical school outside the United States or Canada. Known as non-U.S. international medical graduates (non-U.S. IMGs) to distinguish them from Americans who attend medical school abroad, they totaled more than 203,500 physicians in 2021. Since 2004, their numbers have increased by more than 30%.
Some of these doctors arrive as refugees or as spouses of U.S. citizens and then decide to apply for a residency slot. But most start the residency application process during medical school back home or soon afterward.
That process involves competing in the Match®, the same program that connects U.S. medical school graduates with residency programs. Over the past decade, the number of active non-U.S. IMG applicants in the Match® hasn’t changed dramatically despite occasional fluctuations. Last year, it was 7,864.
But interest in these candidates is growing, experts say. From 2013 to 2022, the portion of non-U.S. IMGs who matched into a residency training program rose from 48% to 58%.
“Sometimes I pinch myself and think ‘Am I really here?’ There just are no opportunities like this back home. I’m learning and contributing more than I had even hoped.”
Antoine Beayno, MD, Mount Sinai Hospital
“Increasingly, academic medicine is attuned to the great value that cultural diversity brings to both residency programs and patients,” says William Pinsky, MD, president of the Educational Commission for Foreign Medical Graduates (ECFMG), which certifies IMGs to enter U.S. graduate medical education programs, and CEO of its parent organization, Intealth, which aims to advance the global health workforce.
So who are these international doctors, what do they have to do to get here, and in what ways do they contribute once they arrive?
Do we need international doctors?
“Foreign physicians who come to the United States contribute in many crucial ways. At the most basic level, they provide care that people need — both during residency and, in many cases, for their entire professional lives,” says AAMC Chief Health Care Officer Jonathan Jaffery, MD, MS.
That’s important because the United States is grappling with severe physician shortages. Already, the country lacks more than 17,000 primary care practitioners and more than 8,000 mental health practitioners, for example. By 2034, the U.S. is expected to face a shortfall of as many as 124,000 physicians.
Experts note that many foreign-born doctors provide primary care. “In 2022, 70% of matched non-U.S. IMGs obtained positions in internal medicine, family medicine, or pediatrics,” says Donna Lamb, DHSc, president and CEO of the National Resident Matching Program®. But Lamb notes that demand for non-U.S. IMGs may be increasing in some other specialties as well.
One such field is psychiatry, where 22% of the workforce already comes from outside the United States. “So many psychiatric patients appreciate deeply having a native speaker. It can make a huge difference in therapy,” says Paul Rosenfield, MD, psychiatry program director at Mount Sinai Morningside-West in Manhattan, who trains residents from Colombia, India, and elsewhere.
“Cultural similarities between international graduates and our patients definitely enhance patient care. In addition, these IMGs also help peers and faculty better understand how to care for these populations.”
Joan St. Onge, MD, University of Miami/Jackson Memorial Hospital
At University of Miami/Jackson Memorial Hospital, leaders have been working with foreign-trained doctors since Cuban refugees began arriving in the 1960s.
“Cultural similarities between international graduates and our patients definitely enhance patient care,” says Joan St. Onge, MD, senior associate dean for graduate medical education. “In addition, these IMGs also help peers and faculty better understand how to care for these populations.”
Providers from less-resourced countries also can relate to underserved populations generally —and not just from their home region — adds Sara Wallach, MD, an internal medicine physician with Capital Health in Trenton, New Jersey, who has trained residents from Sudan, Egypt, and Ethiopia.
Non-U.S. IMGs also are more likely to serve in rural, lower-income, or underserved regions.
At the University of North Dakota School of Medicine & Health Sciences, roughly 50% of internal medicine residents hail from abroad, says Dinesh Bande, MD, internal medicine chair. “We only have one medical school in the state, and it can be hard to recruit candidates from other states. So we are happy to have non-U.S. IMGs for many reasons, including that they are very hard-working.”
Meanwhile, a key question remains: Are international doctors taking residency spots from U.S. medical graduates?
Supporters say no, pointing to research that more than 99% of U.S. medical students enter residency within six years of graduation.
“There are enough residency positions for every U.S. graduate,” says the ECFMG’s Pinsky, though he acknowledges that some may not match into their first-choice specialty.
Jaffery adds another point. “In almost every state, some primary care residency slots don’t fill each year even with non-U.S. grads entering these fields,” he says.
How do international doctors get here?
Any non-U.S. IMG hoping to enter a U.S. residency program — and all who want to become a fully licensed U.S. physician must do so for at least a year — face a highly competitive process.
“IMGs who want to come here feel they have to apply to more programs and have to prove themselves more. They may need to have done a lot of research or have very high test scores,” says Beayno.
One of the steps some applicants take is to complete a clinical “away” rotation in the United States during medical school. The goal is to prove their mettle and gain crucial letters of recommendation.
“I slept on my cousin’s couch during a three-month rotation in Phoenix,” says Mexican-born Antonio Ocejo, MD. “I got up at 4 a.m. because I wanted to be the first one to arrive and the last one to leave.” Ocejo is now a third-year resident at Miami’s Jackson Memorial Hospital.
International applicants also need ECFMG certification. That process includes documenting graduation from an ECFMG-approved medical school and submitting a transcript that’s scrutinized to ensure that curricula align with a U.S. medical school education. It includes demonstrating clinical competency, which can be done via various ECFMG pathways (or by having passed the U.S. Medical Licensing Exam Step 2 Clinical Skills test before it ended in 2020). And it entails proving a number of communication and English-language skills.
Applicants also need to figure out where it makes the most sense to apply for residency. Though most programs accept international graduates, some seem particularly interested in them.
Those “IMG-friendly” programs are usually at smaller, community-based hospitals, though they may be affiliated with a larger, university-based one.
But some blockbuster programs — including Minnesota’s Mayo Clinic — also seek non-U.S. IMGs. “We want to recruit the best doctors we can, no matter where they come from,” says Cheryll Albold, PhD, designated institutional administrator for the Mayo Clinic School of Graduate Medical Education.
Once applicants land a residency slot, they face one more hurdle: gaining a visa. And the visa timeframe is tight — about three months from the Match® until residency starts — so programs and the ECFMG provide help with the complex process.
There are two main visa options for U.S. residency training:
An H-1B is for employees, which means an employer can sponsor you for up to three years at a time for a maximum of six years. If you want to stay after that, your employer may be able to help you get a green card, or you will need to pursue another visa.
A J-1 is considered part of a cultural exchange program, and for that, the ECFMG acts as a sponsor. A J-1 is generally easier to get, but there’s a rub: After residency, usually you must return home for at least two years.
So how do J-1 doctors get to stay? They can get certain types of waivers. One popular type is a Conrad 30 waiver — there are 30 per state — which involves agreeing to work in an underserved region for at least three years. Another option is to pursue a visa type that doesn’t require fulfilling the return requirement.
Of course, some physicians return to their country of origin and contribute to health care back home.
“I have had residents from places like Nepal, Jordan, and Ghana,” says Robert Chow, MD, MBA, chair of medicine at the University of Maryland Medical Center (UMMC) Midtown Campus in Baltimore. “These doctors can go home and serve their patients well. But they can also mentor other doctors there, and in that way, impact an entire community.”
How hard is it to adjust to the United States?
International doctors who come to the United States face a long list of to-dos: get a driver’s license, a Social Security card, a cell phone, et cetera. Then there are all the more nebulous adjustments, from clothing styles to watercooler conversations.
“Back home, 99% of my peers are like me. It’s very homogeneous,” says Harim Kim, MD, a UMMC internal medicine resident from South Korea. “Here, I’m a minority."
But Kim says she came to the United States in part to meet diverse patients, and recalls one particularly powerful experience. “In the VA, I got to meet Korean War veterans, and I got to express appreciation from the South Korean people. They helped my country, and now I’m here to help serve them.”
Adjusting also entails adapting to U.S. medicine. Health care systems, teaching styles, and administrative demands may differ, as may expectations about the physician-patient relationship.
“I had no idea how to log into the computer system or to use the pager, and I didn’t feel comfortable presenting [about] patients in English. I was quite scared at first, and I had imposter syndrome,” says Ocejo.
International physicians also sometimes face bias from patients. “I had one patient early in COVID who told me to go back to China,” says Kim, who, like others, notes that such incidents are fairly infrequent.
“In the VA, I got to meet Korean War veterans, and I got to express appreciation from the South Korean people. They helped my country, and now I’m here to help serve them.”
Harim Kim, MD, University of Maryland Medical Center
Whatever the issues, foreign-born trainees tend to have lots of support. The ECFMG keeps in close touch with programs to monitor residents’ adjustment and offers resources such as an upcoming online module on electronic health records.
Programs also provide help, such as pairing residents with “big siblings” from their home region and offering information sessions with experts like immigration lawyers and financial advisors.
But Beayno says he most appreciates the extensive informal support he has received from his colleagues.
Just one month after arriving, an explosion devastated his home city of Beirut. “It was terrifying to see the images, and I was texting everyone I know to ask if they were alive,” he recalls. “Colleagues were literally with me the whole day as I was talking about this and processing it. … I didn’t want to be alone. If not for them, it would’ve been a very different experience.”
What lies ahead?
Given the great need for more doctors in the United States, advocates are calling for legislative changes to allow more non-U.S. IMGs to come here and stay. The AAMC and other groups have asked Congress to expand the number of international physicians who can receive Conrad 30 waivers. That number hasn’t changed in two decades.
Advocates also have urged the government to process visa applications more quickly and smoothly. “There’s almost always a backlog,” says Matthew Shick, AAMC senior director of government relations and regulatory affairs. “This is not just a problem for the residents. It’s a workforce issue because hospitals rely on them for patient care.”
Meanwhile, educators continue to focus on training the international physicians they attract. For his part, Bande would like to see more non-U.S. IMGs join the faculty physician workforce and move up its ranks. “We need to provide more of them with opportunities to become successful educators and be part of the next generation of leaders,” he says.
Internal medicine physician Grace Kajita, MD, supervises many international residents at Montefiore Health System in the Bronx. In fact, 90% of her residents come from abroad. “One of our program’s goals is cultural, linguistic, and geographic diversity,” she says.
But her trainees bring much more than that, she adds. “These residents show so much tenacity in their efforts to get here,” she says. “And they show so much tenacity in their goal of providing excellent patient care. They are pretty remarkable.”