A Guide to Understanding and Supporting International Medical Graduates in Hematology/Oncology by the American Society of Clinical Oncology IMG Community of Practice

Abstract

Purpose:

International medical graduates (IMGs) are an essential component of the oncology workforce in the United States, comprising a third of all practicing oncologists and almost half of hematology/oncology fellows. In this article, we discuss the contributions of IMGs in the U.S. Oncology workforce, review unique challenges faced by IMGs and propose potential solutions to overcome these challenges.

Methods:

The American Society of Clinical Oncology’s (ASCO) IMG Community of Practice was established with the mission to connect, mentor, guide, raise awareness and overcome the challenges unique to IMGs interested in pursuing medical oncology in the United States. The content of this article is based on discussions at the IMG Community of Practice meetings at ASCO’s 2023 and 2024 Annual Meetings.

Results:

IMGs bring an inherent diversity of thought and experience to the oncology workforce. They provide high-quality, culture- and language-concordant care to a diverse population of patients with cancer. However, IMGs in oncology face significant hardships throughout their careers, including visa-related restrictions, psychosocial and cultural struggles, as well as differential treatment while applying for residency and fellowship training, and early career positions. Greater awareness of these challenges among the members of the hematology/oncology community, along with institutional and individual efforts to support IMGs, is warranted.

Conclusion:

We encourage oncology professional and institutions to join our efforts in recognizing the unique paths of IMGs and providing support and advocacy to maximize the potential of IMGs in the U.S. Oncology workforce.

Introduction to ASCO IMG Community of Practice

International medical graduates (IMGs), defined as clinicians who graduated from medical schools outside the United States (U.S.) or Canada, comprise one third of all practicing medical oncologists in the U.S. and nearly half of fellows currently in hematology and oncology training programs.¹ Unfortunately, the contributions from this growing and vital population of culturally diverse and multilingual physicians to patient care and research often go unrecognized, as do the unique obstacles faced by IMGs.² Despite the high representation of IMGs in the oncology workforce, the transition from IMG to licensed practicing physician in the U.S. is exceedingly arduous and overly complex, with innumerable barriers posing major challenges. In spite of the robust representation and contribution of IMGs to oncology care in the U.S., the process of integrating IMGs into the U.S. healthcare system is lengthy and costly, requiring years of tremendous personal and professional sacrifices with no guarantees.

The American Society of Clinical Oncology (ASCO) acknowledges that in order to provide high-quality care for the entire U.S. population, it is imperative to actively promote racial and ethnic diversity within the oncology workforce.³ In 2023, the ASCO IMG Community of Practice was formed with a mission to connect, mentor, guide, raise awareness about, and find potential solutions to overcome the unique challenges facing IMGs interested in oncology.⁴ To achieve these goals, we have created four committees that each focus on a key goal for IMGs, as outlined in Table 1. Its meetings took place during the 2023 and 2024 ASCO Annual Meetings, and gathered major attention from ASCO members.⁵ The ASCO IMG Community of Practice leadership and members seek to provide an overview of the contributions of IMGs to the oncology workforce in the U.S., describe the challenges that come with transitioning to an oncology career in the U.S., and crystalize future action items to support IMGs across different stages of their careers.

Table 1.

The ASCO IMG Community of Practice Committees

	Mission	Planned activities
1. Research and publications	Gather data and insights on the challenges and needs of IMGs in oncology, which can be used for research and advocacy purposes.	i) Conduct research studies serving the committee’s goals. ii) Build collaborations with other researchers examining workforce diversity.
2. Visa, advocacy, and mentorship	Offering guidance on visa-related issues, advocating for IMG-friendly policies, and facilitating mentorship to help IMGs succeed in their oncology careers.	i) Advocacy initiatives. ii) Peer mentorship programs. iii) Develop informative materials. iv) Conduct outreach.
3. Program directors and leadership	To improve the training experience of IMGs in hematology/oncology fellowship programs and ensure that they receive equitable opportunities, resources, and support.	i) Promote a culture of inclusivity for IMGs within residency and fellowship programs. ii) Help program directors gain more experience in supporting IMG trainees. iii) Offer assistance and advice for institutional initiatives aimed at providing support for IMG trainees.
4. Community oncologists	To connect IMGs practicing as community oncologists, support their professional growth, and enhance their ability to provide high-quality care to oncology patients.	i) Organize events tailored to trainees with a focus on community oncology. ii) Compile a current list of job availabilities based on visa status. iii) Advocate for policies that support community oncologists from the IMG community.

Contribution of IMGs to the U.S. Hematology/Oncology workforce

As noted by ASCO, there remains a significant deficit in the supply of oncologists compared to demand, with approximately 32 million Americans residing in counties without available oncology services. IMGs play a critical role in bridging this gap in access to much-needed care.⁶ Many IMGs’ background in delivering care in resource-limited environments in their home countries equip them to effectively serve diverse underserved populations in the U.S., such as minority individuals, patients and families facing language barriers, rural communities, and those impacted by socio-economic deprivation.⁷

The inherent diversity of thought and experience that IMGs bring from their home countries to the U.S. offers a critical opportunity for our profession to achieve equal, inclusive, and compassionate medical care. Existing literature shows that patient outcomes achieved by IMGs are widely comparable to the graduates of U.S. allopathic (USMD) or osteopathic (USDO) schools and possibly superior, as noted in a study of Tsugawa et al. demonstrating lower 30-day mortality rates in Medicaid patients treated by IMGs.⁷ IMGs also possess unique and diverse clinical and personal experiences, familiarity with diseases that are less prevalent in the U.S., and a deep understanding of different cultures, as IMGs themselves frequently belong to minority populations in the U.S. These factors not only contribute to compassionate patient care but also enhance the overall cultural competency within the hematology/oncology workforce, leading to a more inclusive and diverse care team and improved outcomes.

The residency and fellowship match processes, both essential steps to a career in hematology/oncology, scrutinize candidates (including IMGs) and often select those with greatest level of clinical, research and volunteer experience.⁸ IMG applicants to hematology/oncology fellowship have greater research productivity based on mean number of abstracts and publications when compared to USMDs.⁹ These trends in research productivity carry through to the later career stages among IMGs.¹⁰ As a result, IMGs represent a highly productive subset of hematologist/oncologists, contributing to the progress of our field through scientific publications, global research collaborations, presentations at national and international conferences, and volunteering for professional organizations.

Additional steps to better integrate IMGs into the workforce, and harnessing their capabilities, requires a greater understanding of the unique challenges that they face as they seek to establish a career in the U.S. The remainder of this article will explore the challenges faced by IMGs, including barriers encountered during the residency and fellowship application process, the complexities of the visa system, and the cultural and psychosocial struggles of IMGs in training and clinical practice.

Challenges specific to IMGs pursuing oncology training in the U.S.

Residency and fellowship applications

The residency and fellowship match processes present distinct challenges for IMG applicants. The National Resident Matching Program^® (NRMP) reports the percentage of unmatched applicants for the internal medicine match in 2023 as 1.1% for USMDs, 3.1% for USDOs, 32.4% for US-IMGs, and 40.2% for non-US IMGs.¹¹ Although NRMP Match data can provide insight into applicant outcomes, interpreting match trends requires considering national rankings, location, and other characteristics and offerings of residency programs. Indeed, even larger discrepancies emerge when considering the practice settings of residency programs. ¹² Reddy et al. reported that the proportion of IMGs within programs was 55–70% among community-based programs versus 22–30% among university-based programs. Interview and ranking positions allocated to IMGs were 45% among community-based programs and 15% among university programs. Further analysis provided insight into program directors’ perceptions of recruiting IMGs, revealing broader departmental concerns regarding a potential negative impact on program reputation of recruiting IMGs among the majority of the university programs and more than one third of the community programs surveyed.¹² Notably, this study merged university programs and university-affiliated community programs into one category, leaving the specific proportion and attributes of IMGs matching into university programs unknown. Interestingly, Jenkins et al. reported systematic clustering of residency programs based on the IMG, USMD, or USDO status of residents.¹³ Only 16% of all residency programs met the prespecified criteria for being integrated, defined as having USMD residents between 30% and 65% of the program.¹³ Most of the USMD-dominated programs were identified as university programs, whereas IMG-dominated programs mostly belonged to the community or university-affiliated community categories. This underscores the limited opportunities for IMGs to match at university programs that provide opportunities for more academic-focused training.¹³ The disparities in match rates of IMGs vs. USMDs, and in IMG representation at community vs. university programs, are not dependent on academic or scholarly output and instead reflect in part the perception among program directors that IMGs lower a program’s reputation.

Many IMGs seek postdoctoral positions in the U.S., including internships, externships, observerships and research positions, in order to increase the caliber of their eventual residency applications. Such positions, which may last 2–3 years or more, are limited in availability, highly competitive, and often unpaid. In order to secure these positions, IMGs often contact hundreds of investigators in the U.S., devoting a considerable amount of time to searching for employment-related information in the U.S.¹⁴ These positions can impose major financial strain on IMG applicants who often arrive from countries with comparatively lower average income, perpetuating a selection bias within the population of IMG applicants in favoring those coming from more financially secure backgrounds. Few data exist regarding the experiences of IMGs who pursue these positions, and it is unclear whether such positions actually bolster applicants’ match prospects or merely prolong the training process for IMGs, making them older than their USMD or USDO counterparts when applying for residency and fellowship training. ^2,14

Hematology/oncology remains one of the most competitive sub-specialties in the fellowship match as evidenced by 22.5% of applicants going unmatched in the 2023 Match, which is among the highest rates across all specialties.¹⁵ Both non-US IMG and US IMG applicants typically have a higher number of scholarly works compared to USMD applicants with mean number of abstracts/publications of 16.5 for non-US IMGs, 12.5 for US IMGs, and 9.1 for USMDs. Considering that IMGs are most commonly trained in community settings, in which research opportunities are limited, these figures underscore IMGs’ constant academic drive despite disparities in fellowship match process. Butt et al. elaborated on these disparities by asking hematology/oncology program directors what level of advantage/disadvantage was perceived for distinct demographic groups of applicants.² Importantly, non-US citizen IMG applicants were unilaterally viewed by fellowship program directors as being the single most disadvantaged demographic group among all other groups, including historically underrepresented minorities, women, and sexual minorities.² While numerous workforce diversity initiatives are enforced by law to protect against unjust treatment of individuals based on certain demographic characteristics, IMGs as a group do not have legal protection against discrimination and are therefore a key vulnerable group in need of equitable opportunities.

The hardships that IMGs endure to secure positions in the U.S. residency system are based on the current standard that physicians must complete training in a U.S. residency program before practicing in the U.S. However, recognizing the severity of the physician workforce shortage in the U.S., initiatives have recently been implemented that draw upon the tremendous potential of the IMG talent pool to offset this shortage. A recent law in Tennessee, signed in April 2023, allows physicians who have been fully trained abroad to practice under a provisional license within a hospital that has an Accreditation Council for Graduate Medical Education-accredited residency program (while not being enrolled in the program), with the goal of transitioning to a full medical license after 2 years. Such programs could allow communities to decrease physician shortages and allow fully trained IMGs to not repeat their post-graduate training in the U.S. Other states are considering similar programs, the outcomes of which will be closely followed.¹⁶

Despite the growing expansion of national initiatives focused on promoting workforce diversity, the real and perceived biases towards IMG applicants aspiring to serve the U.S. population remain a challenge. Efforts at both the individual and institutional levels should be directed toward evaluating IMG applicants holistically, taking into account their track record of accomplishment and determination to succeed in a competitive environment rather than a major reliance on focusing on non-modifiable factors such as country of origin, citizenship, or visa status. Furthermore, it is important to recognize the fact that the trials and tribulations of IMGs across the stages of their careers, from residency training to independent practice, render them an exceptionally resilient group of physicians with immense potential to contribute to the workforce in both clinical and research settings.¹⁷ Table 2 summarizes our recommendations for fostering IMGs through their transition into the hematology/oncology profession.

Table 2.

Recommendations from ASCO IMG Community of Practice on ways to support IMGs throughout their careers.

Residency and fellowship application process

1) Mentors, instructors, and colleagues

a. Recognize the capacity of an individual to overcome past challenges as an indicator of their future potential, particularly when encountering IMGs seeking research or mentorship opportunities.

b. When mentoring an IMG, understand their needs in preparation for the next phase of their careers (i.e., residency or fellowship application), and align mentorship efforts with research experiences, conference presentations, publications and/or networking skills according to their needs.

2) Institutions and organizations

a. Tackle negative and biased perceptions among leadership about the reputation of the program when recruiting IMGs.

b. Evaluate residency and fellowship applications from IMGs holistically.

c. Shift attention away from non-modifiable factors (country of origin, citizenship, visa requirements); focus on modifiable factors (U.S. clinical experience, research experience, exam scores); and, most importantly, consider applicants’ personal challenges, perseverance, and determination.

d. Work towards eliminating unpaid research positions for IMGs.

Visa-related restrictions and challenges

1) Mentors, instructors, and colleagues

a. Become familiar with specific requirements of each visa status.

b. Acknowledge and validate the challenges IMGs go through due to visa-related travel restrictions.

c. Advocate for trainees encountering challenges in securing jobs in their desired setting (i.e. academic, or private practice job) in institutional and national platforms.

2) Institutions and organizations

a. Establish structured programs to assist trainees on visas (i.e. consultations, seminars with immigration lawyers) as early as the onset of their training.

b. Advocate for institutional initiatives offering visa options that do not portend restrictions to the goals and aspirations of a trainee.

c. Establish institutional financial support and offer flexibility for trainees going through the permanent immigration process to request time off.

d. Refrain from imposing visa-related restrictions on grant eligibility and encourage grants directed to non-US citizen researchers and trainees.

e. Tailor J-1 waiver job offerings based on the local density of hematology and oncology specialists.

f. Advocating with states and lawmakers to expand J-1 waiver programs within high-resource research settings and alleviate the limitations associated with J-1 visa status, particularly for academically driven individuals.

Psychosocial support

1) Mentors, instructors, and colleagues

a. Regularly check in with the trainees and colleagues, specifically in the event of a conflict or natural disaster in their home country.

b. Do not overlook the struggles unique to IMGs including geographic distance from previously established support mechanisms, cultural and linguistic barriers, health problems of loved ones living far away.

2) Institutions and organizations

a. Establish IMG support networks within the department and across the institution.

b. Include professionals familiar with struggles of IMGs within the employee support teams to provide individualized support.

c. Prioritize efforts to accommodate needs of trainees requiring long-distance travelling to visit family, especially in the setting of an urgent/emergent event.

d. Establish training support for trainees unfamiliar with financial planning and investments in the United States

Miscellaneous

1) Reevaluate mentorship goals, not only focusing on research productivity, but also academic promotion and career satisfaction, and adjust plans to meet needs.

2) Encourage research on IMG wellbeing and mechanisms to support IMGs.

3) Establish funding for quality improvement projects for inclusion of IMGs in diversity, equity, and inclusion efforts.

4) Encourage studies of the research output, academic trajectory, and leadership contributions of IMGs.

Visa restrictions

The complex visa system influences decision-making throughout an IMG’s life and career. A survey of hematology/oncology fellows noted that 74% of trainees in fellowship consider visa status as one of the major factors in guiding their career choice.¹⁸ Figure 1 details two major visa options (i.e., J-1 exchange visitor visa and H-1B visa) available for IMGs and a general timeline of career events that can be impacted by visa status.

Figure 1.

Most common visa options (J-1 exchange visitor visa and H-1B visa) available for IMGs and a timeline of career events that can be impacted by visa status.

J-1 visas are sponsored by the Educational Commission for Foreign Medical Graduates (ECFMG) and remain the most common visa option in training programs. J-1 visas require annual renewal, which necessitates trainees travel to their home country for an often-prolonged visa renewal process. This, in turn, could cause delays in their return to residency or fellowship programs, leading to significant distress on both the trainee and their programs. Furthermore, many J-1 visa holders are subject to a 2-year home country physical presence rule after completion of training. The 2-year rule imposes restrictions against staying in the U.S. as a physician or transitioning to immigrant visas unless the physician pursues a waiver of the 2-year rule. Such waivers are limited to certain categories, most commonly through the Conrad 30 program, which requires a physician’s commitment to practice medicine in an underserved area of the U.S. for three years. Although this program inherently serves a worthy and vital cause, underserved areas are defined based on a shortage of primary care physicians, as well as socio-economic and healthcare accessibility factors, with no accounting for access to hematology/oncology care.^19,20 The designation of an area as medically underserved does not consider the density of sub-specialists such as hematologist/oncologists, and there is no concordance between the density of practicing oncologists and the percentage of IMGs.¹⁹ Accordingly, whether this program serves its desired purpose in promoting access to oncology care remains unknown, as even in medically underserved areas, the J-1 waiver job options for hematologists/oncologists are often limited.²⁰ Furthermore, because J-1 waiver jobs are scarce at academic institutions, early career IMG oncologists with aspirations in academia may be steered towards transitioning to community practice.

An alternative option for fellowship graduates with significant research achievements, who wish to stay in academic medicine, is to transition from a J-1 visa to an O-1 visa. This visa, which is initially awarded for a 3-year period followed by the potential for continued 1-year extensions, does not require the applicant to have received a J-1 waiver. Once applicants have joined faculty on an O-1 visa, there is then the potential to apply for an Interested U.S. Federal Government Agency waiver of the J-1 2-year home residency requirement. For academic oncologists, this would involve their institution assisting in preparation of an application to the National Institutes of Health (NIH), who may then request that the Department of Health and Human Services consider waiving the home residency requirement. Relatively few academic institutions in the U.S. have been open to this pathway, perhaps partly due to lack of knowledge or experience with the process and the requirement for significant and continued academic achievement. We strongly advocate for two key initiatives: (1) customizing J-1 waiver job offerings to address the pressing need for hematologists/oncologists in underserved areas, in order to enhance access to cancer care and improve outcomes for patients in need; and (2) expanding the J-1 waiver programs to high-resource research settings. This can alleviate the limitations associated with J-1 visa status to IMGs who want to pursue an academic career.

H1-B visas pose fewer restrictions on future employment or visa options should trainees stay in the U.S. However, H1-B visas are offered by fewer training programs, primarily because the hospital and programs are responsible for sponsoring the visa, handling the required paperwork, and covering the associated costs, rather than ECFMG.²¹ IMG physicians working for non-profit entities that are related to or affiliated with an institution of higher education could be exempt from the annual cap on the number of H1-B visas issued each year, thus enabling visa petitions to be filed year-round.²² Notably, H1-B visas are also advantageous as they allow transitioning to permanent residency while in an H-1B status through various employment-based, family-based, and research merit-based mechanisms. Additionally, even among physicians who are eligible to apply for permanent residency, applicants often face long backlogs for some categories of applications for permanent residency; this is particularly the case for applicants born in China, India, Mexico, or the Philippines.

The challenges faced by IMGs due to their visa status begin with their initial application for internal medicine residency training, as, in general, transitioning from a J-1 visa to an H1-B visa or permanent residence is not permitted unless J-1 waiver conditions are met. Only 63% of internal medicine residency programs reported acceptance of a visa holder; 42% were noted to exclusively offer J-1 visas, while only 22% offered both J-1 and H1-B visa options.²¹ While J-1 visas provide hiring institutions with more flexibility during residency and fellowship recruitment, they may not be entirely suitable for trainees with academic ambitions. We strongly urge institutions to create pathways for alternative, less restrictive visa options for trainees, such as H1-B visas. It is imperative to involve trainees in the decision-making process regarding the visa type that best aligns with their preferences and future needs. Despite the substantial presence of IMG trainees and faculty, most institutions lack structured counseling mechanisms for visa-related issues, and the complexities of the visa process remain unfamiliar to training program administrators and institutional leadership.

Foundational grants comprise the majority of research funding provided to visa-holding IMGs, as applicants on visas are not eligible for the majority of grants offered by the NIH. A number of other federal grants, such as those provided by the Department of Defense, do not impose restrictions based on visa or citizenship status. Young Investigator Awards, provided by several institutions (including ASCO), offer an invaluable step in career development of trainees as they transition to their independent careers and do not restrict applicants based on citizenship or visa status. However, the vast majority of these grants restrict eligibility solely to those within 10 years of medical school graduation. Given the extended time IMGs dedicate to transitioning into a career in the U.S., including time spent in research endeavors, residency, and fellowship training, this disqualifies a significant proportion of IMGs from these opportunities. We advise funding institutions to consider the unique career paths of IMGs when determining award eligibility and provide detailed eligibility criteria concerning visa status and year of graduation to ensure complete transparency and accessibility to a diverse pool of applicants.

The implications of visa status persist throughout the careers of IMGs, influencing the job search process, contribution to research, and overall wellbeing among IMGs in hematology and oncology. We proposed steps to support IMGs throughout the visa process in Table 2.

Psychosocial and cultural challenges unique to IMGs

The safeguarding of physician wellbeing has emerged as a critical area of attention in the field of oncology, with the prevalence of burnout escalating to an alarming 50% among hematology/oncology physicians.^23–29 A third of interns exhibit signs or symptoms of clinically significant depression.^30–33 Although the patterns of burnout and clinical depression among IMGs in oncology throughout their careers is as yet uncharted, the aforementioned challenges unique to IMGs surely contribute to this burden.

Despite the fact that most of the above-mentioned reports did not focus on IMGs as a subgroup, the survey of 7,817 trainees holding J-1 visas shed light on the unique challenges facing IMGs.³⁴ Respondents noted their most significant challenges to be the impact of cultural differences, adapting to a new healthcare system, and distance from family and friends. The key areas of support suggested by respondents were related to socialization, bureaucratic support, IMG support networks, mentorship, and financial and immigration support.³⁴ Discussions at the IMG Community of Practice meetings were in alignment with these findings. Table 2 summarizes individual and institutional support mechanisms suggested by the ASCO IMG Community of Practice.

IMGs encounter a myriad of personal challenges as well, including loneliness, lack of social and financial support, travel restrictions, the burden of leaving loved ones behind, worries about the health of family and friends at home, and struggles stemming from conflicts back in their home country. Furthermore, IMGs may encounter discriminatory language, intimidation, and workplace misconduct due to their country of origin, accent, immigration status, religion, lifestyle and potential limitations in adhering to social norms of the U.S. ^35,36 Establishing a safe and productive work environment depends on strong mutual care, respect, and support. We should all stand as allies to IMGs and remain mindful of the potential psychosocial difficulties they can face, including isolation, self-doubt, lack of social support mechanisms, and the challenges of being away from loved ones.

Conclusions

In this article, we outlined the key challenges faced by IMGs in oncology and potential next steps for mentors, colleagues, institutions and organizations aiming to better support IMGs. The ASCO IMG Community of Practice will aim to build on its initial meetings to continue to support and advocate for IMGs. We invite oncology professionals across the country to join our efforts in honoring the contributions of IMGs to patient care and scientific progress in the U.S., and in recognizing their unique paths, offering guidance, support, and advocacy.