Incoming International Medical Graduates and the COVID-19 Pandemic: More Than Meets the Eye

On March 26, 2020, the US Department of State issued an update encouraging international medical graduates (IMGs) with approved non-immigrant or immigrant petitions or those eligible for the Exchange Visitor Program to request visa appointments, a few days after suspending all services worldwide in response to the COVID-19 pandemic.¹ In addition, health care workers and their families were exempt from President Trump's executive order issued on April 22, 2020, suspending all forms of immigration to the United States.² Aiming to avert a national health crisis during this pandemic, these immigration exemptions complement other national efforts to immediately expand the health care workforce by offering early graduation to medical students³ and relocating volunteer health care workers to devastated states.⁴ Although IMGs may have evaded immigration and visa processing restrictions at the moment, the global nature of this pandemic poses another set of challenges for more than 4200 non-US citizen IMGs who have recently matched at US graduate medical education (GME) training programs. In this perspective, we highlight some of these challenges and offer innovative and practical recommendations for US GME stakeholders to minimize disruptions in patient care and IMG training.

IMGs are an essential part of the US health care workforce, representing a quarter of all practicing physicians, including the GME training pool, and make invaluable contributions to patient care, medical research, and education.⁵ Many are currently engaged in treating patients during the COVID-19 pandemic in the United States—40% of infectious disease residents and fellows are IMGs.⁶ Data from the 2020 National Resident Matching Program show that 7376 (23%) of the 32 399 matched postgraduate year 1 positions were filled by IMGs, of whom 4222 (57%) are non-US citizens⁷ and set to join specialties at the frontlines of this battle; 25% of all internal medicine positions this year were filled by non-citizen IMGs. The role of incoming IMGs during this crisis cannot be overstated.

The timely and smooth transition of recently matched IMGs to their GME training programs this summer is contingent on several geopolitical, bureaucratic, logistical, and personal factors that stem from the global spread of this crisis in a world with finite health care resources (Table). Although the United States has recently become the epicenter of the COVID-19 pandemic,⁸ many countries with fewer health care resources are facing grim outcomes. The number of IMGs seeking US GME training in some of these countries varies.⁵ Therefore, global geopolitical leaders are faced with an ethical dilemma: Should these physicians be allowed to travel to the United States or should they join their local health care workforce that may need their services even more? While countries with adequate resources may allow IMGs to treat patients in the United States, others may choose to retain their physician workforce by implementing travel bans or refusing to issue statements of need, which is a prerequisite for J-1 visa processing. Other bureaucratic challenges that may potentially disrupt travel plans include government office closures during lockdowns and commercial flight bans.

Table.

Challenges and Potential Solutions for IMGs Transitioning to US Graduate Medical Education Programs During the COVID-19 Pandemic

Challenges	Potential Solutions	Examples
Geopolitical Challenges Affecting IMG Travels
• Countries implementing travel bans on their citizens or refusing to issue statements of need for the J-1 visa • US immigration limitations that may be imposed by the US administration • Governmental office closures • Commercial flight cancellations	• Stakeholders such as the ACGME, ECFMG, and AMA must continue to lobby for the removal of obstacles facing IMG travel plans • Structuring global electives that fit ACGME core competencies • Arranging schedules with frontloaded global health, research, and teaching electives • Introducing telemedicine rotations where IMGs can participate in direct clinical care of US patients remotely • Modifying GME leave of absence policies to accommodate for extended unpaid leaves of absence if needed, allowing IMGs to begin their training the following year	• The ECFMG, AMA, and ACGME lobbying for physicians to be able to apply for work and immigrant visas despite the US government suspending visa services early in the COVID-19 pandemic • ECFMG asking the Department of State to allow J-1 visa holders to enter the United States earlier than 30 days before the program start date • Encourage IMGs to engage in vetted global health electives, particularly ones where they can contribute to the battle against COVID-19
Logistical Challenges Facing IMGs Upon Arrival to the United States
• Processing paperwork: social security numbers, medical licenses, and driver's licenses • Securing housing • Family relocation • Opening bank accounts and receiving salary payments • Health and disability insurance	• Assistance with paperwork as early as possible • Providing resources for housing and schools as soon as the contract is signed • Provide a salary advance upon the arrival of the resident to the United States	• Institutional IMG liaisons may begin conversations with local DMVs and social security administration officials about whether such paperwork can be completed remotely • Create a payroll advance policy
Personal Challenges
• Leaving families behind and their home countries in a time of need • Uncertainty regarding the ability to return home	• Providing necessary emotional and psychological support to IMGs as they make this difficult transition • Flexibility with vacation scheduling in order to allow for them to return home when possible	• Provide psychological, financial, and legal support to families of IMGs in the event their loved one suffers a serious complication of COVID-19 or dies while on duty9

Abbreviations: IMG, international medical graduate; GME, graduate medical education; ACGME, Accreditation Council for Graduate Medical Education; ECFMG, Educational Commission for Foreign Medical Graduates; AMA, American Medical Association; DMV, Department of Motor Vehicles.

But the challenges don't stop there. If IMGs do manage to move to the United States on time, they may face logistical challenges in areas with strict lockdowns such as issuance of driver's licenses and social security numbers required for salary payroll and medical licensure. Once in the United States, traveling back to their home countries may be another predicament as the pandemic endures. Finally, recently matched IMGs face several personal challenges; most importantly, the heart-aching conflict of leaving their homes in times of uncertainty. Putting their lives on the line to practice medicine during this time feels like a duty, but the decision to do this in the United States instead of at home is a difficult one to face. These residents will leave their families and friends behind, uncertain of what will happen to them in the face of this pandemic so will need to have faith that they are contributing positively to the global pandemic efforts.

Given these challenges, US GME sponsoring institutions and program directors must be prepared with innovative and practical solutions that minimize the disruption of optimal patient care and IMG training schedules (Table). First, powerful stakeholders, such as large academic institutions, the Accreditation Council for Graduate Medical Education (ACGME), and the Educational Commission for Foreign Medical Graduates (ECFMG), must continue to strongly lobby for the resolution of all political and bureaucratic obstacles that may hinder or delay IMG travels. As immigration policies continue to evolve, all stakeholders must continue to closely monitor the situation and relentlessly remind policymakers that IMGs are essential to combating this crisis. Second, program directors are urged to schedule some IMGs to start with rotations that can be completed remotely. Global health electives have become a standard offering, with recent surveys showing that 70% to 91% of GME training programs offer this experience.¹⁰ Suggestions include shaping global electives to include ACGME core competencies for the specialty and to ensure resident learning and professional developement.¹⁰ We recommend that program directors immediately communicate with incoming IMGs to assess their travel situations and discuss options for global health electives. We also recommend developing telehealth rotations in which IMGs can practice transcontinental telemedicine with appropriate supervision per ACGME guidelines.¹¹ Telehealth rotations will allow IMGs to remotely engage in direct clinical care of US patients and also free up US trainees for necessary hands-on work. Other options for remote electives might include international research or teaching electives (perhaps COVID-19 related), which would allow IMGs to contribute to the scientific and educational efforts to curb the pandemic. Lastly, sponsoring institutions are encouraged to modify their GME unpaid extended leave of absence policies to accommodate significant travel interruptions.

In addition to developing contingency plans for travel delays, GME programs should carefully plan for the arrival of IMGs this year. Programs, especially in areas with strict lockdown measures, should anticipate difficulties with processing paperwork and navigating complex systems. For example, if salary payroll enrollment is delayed, advanced payments might be considered. Assisting IMGs and their families with the relocation process such as finding a new home or choosing health and disability insurance is also essential to enhance the focus on patient care and residency responsibilities. We also recommend that residency psychological, financial, and legal resources be communicated and offered to IMGs and their families if they become ill. Finally, IMGs must do their part and start to plan immediately for this transition by tracking flight restrictions, making early bookings, and rapidly initiating all the necessary paperwork for themselves and their families.

The promise of high-quality medical training, meritocracy, and equality has always made pursuing medical practice in the United States worthwhile. Currently, more than 4000 recently matched IMGs are facing formidable challenges in their transition to GME training. While the current state of uncertainty is anxiety provoking for IMGs and the GME community, we must be prepared with unconventional solutions that minimize disruptions to patient care, the training of IMGs, and their career aspirations.