My New Country: A Journey to Belonging

It was one of those days when I could not push back the gnawing feeling I had tried to bury all those years I have been away, the homesickness that grows back stronger every time. I really thought that staying away would make it more bearable. Eight years ago, I packed as much as I could of my previous life in a couple of suitcases and left family, friends, and a part of myself to embark toward the unknown, seeking a better medical future. Eight years ago, I became a foreign-born international medical graduate.

The Educational Commission of Foreign Medical Graduates defines an international medical graduate (IMG) as “a physician who received his or her medical degree from a medical school located outside the United States and Canada.”¹ I belonged to the foreign-born group as opposed to US-born IMGs. We, IMGs, make up approximately one-fourth of US practicing physicians, and almost one-third of the residents enrolled in programs accredited by the Accreditation Council for Graduate Medical Education (ACGME).^2,3 Foreign-born IMGs may have different medical paths—coming right after completing medical school abroad, after residency/fellowship, or after several years of clinical practice—but we share 1 ultimate goal: joining an ACGME-accredited program. The emigration of foreign-born IMGs to the United States constitutes a “medical brain drain.” I had already successfully finished my internal medicine residency along with an endocrinology fellowship back home, and yet I was joining the pool of physicians applying to the National Resident Matching Program. The road leading to being a foreign-born IMG was expensive and emotionally draining. Nevertheless, the e-mail announcing that I had secured a position made me forget about all the costs of the “Match” and international travel for interviews.

So here I was, a legal alien physician. Like every foreign-born IMG, I worried about integrating with the residency crowd, about “not being good enough” or “not up to the expectations,” and promised myself to work hard and prove myself. The first challenges were not medical, though, but related to not having a social security number, and, even worse, a credit history to secure a car or a phone. At the hospital, cultural differences were obvious. Being fluent in English and passing the United States Medical Licensing Examination Step 2 Clinical Skills could not have prepared me to colloquialisms, such as drinking “pop” or having “the runs.” The simple introduction of myself betrayed my accent, and inevitably led to “Sorry, what's your name again, Doctor?” “How do you spell it?” and “Is it OK if I call you Dr C?” And so, I joined the ranks of physicians best known by the first letter of their last name.

I was a fully trained endocrinologist going again through intensive care rotations and central line insertions. My US residency was not ending fast enough as I watched, on a daily basis, the endocrinology consult team perform their rounds and aspired every day to rejoin the endocrine world. The concepts of health care reform, patient engagement, and satisfaction were as foreign to me as I was to this country. Still, I was here to learn, with lots of perseverance, adaptability, and will. I had the help and support of wonderful colleagues and kind hospital staff. Checklists, well-organized processes, and guided mentoring made my integration easier than expected.

Similar to all foreign-born IMGs, it was crucial that I familiarize myself with the process of maintaining legal status in the United States and pertinent immigration policies, including J-1 and H-1B visas, J-1 waivers, permanent residency (“green card”), and ultimately, the holy grail of naturalization. As a J-1 Visa (exchange visitor program) holder, I would be required to practice in my home country for 2 years before being able to work again in the United States. This requirement could be waived if I agreed to work in an underserved area in the United States under a J-1 waiver. Once more, I was facing a new challenge, a new deadline: my quest of a waiver position. Thanks to the Conrad Program,⁴ a program aimed at addressing physician shortages, I had a chance to practice medicine in the United States, and switch to a working H-1B Visa. A limited number of J-1 waivers for each state is dispensed on a first-come, first-served basis. Applying for a J-1 waiver thus becomes a race against time. The wait for my approval was high-stakes suspense, and the endgame could mean deportation and the premature demise of my dream. As I finished my second year of fellowship, I focused on finding and applying for a waiver, working closely with immigration and hospital lawyers, and ensuring the timely filing of my paperwork in order to meet the narrow application window for the program.

In retrospect, going through the J-1 waiver process was one of the most stressful periods of my life. Once on an H-1B Visa, and after my 3-year waiver, my transition to permanent residency was possible through the sponsorship of my employer. As I navigated through this complex process, I was exposed to constant hand-wringing about the physician shortages in the United States. It was unconceivable how such a maddening system came to exist despite a high demand for physicians.

Foreign-born IMGs are mainly engaged in clinical care with minor representations in medical education, research, and administration.⁵ Obviously, as a J-1 waiver applicant, I had limited choices for placement jobs, which were mainly geared toward clinical practice. All through my waiver period, my dreams of a career in academia and medical education haunted me. I knew the return from waiver into an academic or research track was possible, yet it would be challenging. Foreign-born IMGs tended to become more accepting of their predominantly clinical role, and less likely to fight inertia. The longer I stayed in my waiver position, the more effort and diligence I would need to persevere and reincorporate as an academician. On the other hand, I always wondered if academic institutions might be suspicious of my research and education potential, and reluctant to reintegrate me into their systems.

It has been a long journey to becoming a foreign-born IMG, and ultimately a US citizen, and it was well worth the effort in view of the wealth of opportunities to excel in the United States. After the melting pot of my US training, I arose with a richer, more diverse cultural and educational heritage. Like most foreign-born IMGs, I was regarded as a hard-working and intensely dedicated physician (I hope!), but I have no doubt that my recruitment was associated with quite a bit of hassle for my training programs and employers, due to the immigration and legal restraints.

I am immensely grateful for the opportunities that were provided to me as I have passed successfully through the different stages of the system. After all, the United States is still the “land of opportunities,” as available resources help forge our medical experience and explore our potential to its best. As a foreign-born IMG, I am also an immigrant at heart, with a feeling of uncertain belonging. My roots pull me toward my native country, where I still have family, childhood memories, laughter and knee scratches, adolescent love, and my first initiation to medicine. It is there that my mind drifts endlessly, and my soul longs for the happy memories flavored with nostalgia. On the other hand, I feel attached to the country that has embraced me and is helping me thrive as a physician. As the uncertainty is slowly transcending into a richer, dual belonging, the journey continues.