The U.S. is facing a severe shortage of doctors. International medical graduates (IMGs) are picking up the slack in a major way and often practice in physician shortage areas and communities with limited access to health care services.
There are several programs offering IMGs incentives to practice in these locations, but that doesn’t mean the gates have swung wide open to welcome them. IMGs must too often play a stressful waiting game to learn whether they’ve been selected for these programs.
Such was the case for Afifa Adiba, MD, an IMG from Bangladesh who was willing to work in a community with limited health care access. She had completed a fellowship at the Yale Child Study Center and specialized in the high-demand field of child and adolescent psychiatry.
But, as a new mother with an expiring J-1 visa, she had few options. The prospect of separation from her family—for either two years by going back to Bangladesh or for three years by relocating to a remote area in the U.S. Delta Doctors program—was very real after she failed to land a position under the Conrad 30 program.
“It was hard for me because my husband has a job, and thought I might have to leave him with my 3-month-old daughter—the nights I spent without sleep and the amount of pressure I went through—it was stressful,” said Dr. Adiba, a child and adolescent psychiatrist and a delegate on the AMA International Medical Graduates Section governing council.
Dr. Adiba’s story is only one of many from IMGs frustrated by the maddening process of becoming permanent practicing doctors in the U.S. who can help fill badly needed gaps in care and alleviate physician shortfalls.
Earlier this year, the AMA provided written testimony (PDF) to the U.S. House Judiciary Committee’s Subcommittee on Immigration and Citizenship that hailed the role played by IMG physicians to fill gaps in health care access during the COVID-19 pandemic.
The pandemic “forced states to recall retired physicians, expand scope of practice, and temporarily amend out-of-state licensing laws,” says the AMA’s statement.
“However, none of these adjustments will fill the physician shortage gap long term,” the statement adds. “As such, additional physicians, in the form of international medical graduates ... are greatly needed. IMGs often serve in rural and medically underserved communities, providing care to many of our country’s most at-risk citizens.”
Other points raised in the 11-page statement, prepared by the AMA Division of Legislative Council, include calls to:
- Promote an increase of IMGs and that current IMGs should not be “hampered by additional unnecessary regulations in the midst of helping the U.S. fight COVID-19.”
- Promote and ease the way for IMGs to enter the U.S. workforce.
- Decrease the stress that IMGs face when applying for visas and green cards.
- Lift restrictions for IMG physicians with H-1B status that confine them to working at only one location.
“If smoother pathways are created for IMGs the positive impacts on U.S. health care will be great, particularly in rural and urban medically underserved areas of the country where J-1 physicians represent a much higher percentage of the trainee and practicing physician workforce,” the statement says.
In May, the AMA supported the bipartisan “Conrad State 30 and Physician Access Reauthorization Act,” which would reauthorize the program for another three years, expand the number of waivers states can obtain each year and exempt physicians and their families from numerical immigration limits The Consolidated Appropriations Act of 2022 (signed into law in March) included an extension of the Conrad 30 program through September 2022. After that time more negotiations will take place for further reauthorization.
“Nearly 21 million people live in areas of the U.S. where foreign-trained physicians account for at least half of all physicians,” AMA Executive Vice President and CEO James L. Madara, MD, wrote in the letter (PDF). “As such, it is important to support and create pathways for these physicians to be able to continue to remain in the U.S. and care for their patients.”
For Dr. Adiba, she was left with few choices.
Under Conrad 30, the requirement for nonimmigrant IMG J-1 visa holders to return to their home country for two years is waived. But that waiver comes on the condition that the physician enter an employment contract to practice medicine as an H-1B nonimmigrant for at least three years in a designated health professional shortage area, or do so for a population with limited access to medical services. Each state can do this for up to 30 IMG physicians.
“It’s like a lottery process. You have your name picked out to get into the program,” Dr. Adiba explained.
She applied in November 2020 and had to wait four months to find out whether she was chosen. Meanwhile, her J-1 visa was set to expire in June. The wait was excruciating. Then the word came that her name was not picked.
“Being a new mother, I felt like I was going through depression, and I was just lost, because I trained at an Ivy League institution, I definitely wanted to serve an underserved population—that has always been my passion,” she added. “I felt like I was left out just because of my visa issue, but what could I do? I feel very emotional now talking about that.”
Although she was highly qualified and had chosen a specialty with an existing severe shortage, it came down to luck that she was able to land her position with Towson, Maryland-based Sheppard Pratt—which describes itself as “the largest private, nonprofit provider of mental health, substance use, developmental disability, special education, and social services in the country.”
“Someone in Maryland had to leave, and that created an open spot. And I was next in line, so they gave that spot to me,” Dr. Adiba said. “That's how I ended up getting this job and started working on time.”
Since last July, she’s been working as the service chief for Sheppard Pratt’s adolescent mood disorders inpatient unit.
“I love what I do,” Dr. Adiba said. “I feel like mental health and suicide are the biggest issues among teenagers and that is my specialty. And if I'm making a little bit of difference with one patient, that is my great satisfaction. I don't know what I would do if I was not a psychiatrist.”
From 2007 to 2016, the U.S. supply of child psychiatrists rose to 7,991 from 6,590 (21.3%), but growth was uneven and 70% of the nation’s counties lacked one of these specialists, according to a study by RAND Corp. researchers that was published in Pediatrics.
State ratios of child and adolescent psychiatrists per 100,000 children range from one to 60 with a median of 11, according to the American Academy of Child and Adolescent Psychiatry.
Dr. Adiba knows what these statistics mean.
“If someone wants to see me, they have to wait four to seven months to get an appointment,” she said.
Overall, the U.S. faces a projected shortage of between 37,800 and 124,000 physicians within 12 years, according to The Complexities of Physician Supply and Demand: Projections From 2019 to 2034 (PDF), a report released by the Association of American Medical Colleges (AAMC).
There are about 234,000 IMG doctors practicing in the U.S., which accounts for 23% of the physician workforce, according to the 2020 physician census (PDF) issued by the Federation of State Medical Boards (FSMB). This represents a 24% growth since 2010.
According to 2019 data from the AAMC, the specialties with the most IMGs are:
- Internal medicine: 47,840.
- Family medicine: 28,569.
- Pediatrics: 14,981.
- Psychiatry: 11,800.
- Anesthesiology: 8,722.
“You have to understand, we are the primary care workforce,” Dr. Adiba said, speaking of herself and her fellow IMGs practicing in the U.S. “If we have to leave, it'll have a huge impact.”
The AMA opposed several rules proposed by the Trump administration that would have unduly burdened IMG physicians and that the Biden administration has rolled back. Read more about the rules hindering IMG doctors getting rolled back.
The AMA opposes immigration policies that create unnecessary stress for IMG physicians and their families—especially those that exacerbate the physician workforce shortage and further limit the ability of certain non-U.S. citizen IMGs to receive a visa or green card.
During the 2022 AMA Annual Meeting in Chicago, the House of Delegates directed the AMA to lobby Congress and the Biden administration so that the J-1 visa waiver physicians serving in areas with limited access to health services be given the highest priority in visa conversion to green cards upon completion of their service commitment obligation and be exempted from per country limitation of H-1B to green card visa conversion.
The AMA has adopted a wide range of other policies to support IMG physicians, covering topics such as:
- J-1 visas and waivers.
- Conrad 30 - J-1 visa waivers.
- J-1 exchange visitor program.
- Limits on training opportunities for J-1 residents.
- Visa complications for IMGs in graduate medical education.
- Impact of immigration barriers on the nation's health.
- Permanent residence status for physicians on H1-B visas.
- Employment of noncertified IMGs.
- Principles on IMGs.
- Discrimination in licensure of IMGs.
- Credentialing issues.
Dr. Adiba said IMG physicians and their families deserve more stability.
“It’s so unpredictable, and I don't know where I will go next. So I can only plan for the next few years,” she said. “I know that I'm going to be in this job for the next two years, and after that, I will apply for my green card. I don’t know when I will get that, only then I can move forward.”