Author + information
- Tarek Alsaied, MD∗ ( and )
- Peace C. Madueme, MD
- ↵∗Reprint requests and correspondence:
Dr. Tarek Alsaied, The Heart Institute, Cincinnati Children’s Hospital Medical Center, 3333 Burnet Avenue MLC, Cincinnati, Ohio 45229.
It was graduation day for 1 of the biggest and most prestigious pediatric residency programs in the country. Families came from every state to see their children graduate. Omar’s family could not join him from overseas today, as they were not able to get the visa in time. The big news today was that the resident of the year award went to Omar, who is one of the few international medical graduates (IMGs) in the program. Like many IMGs, Omar was fascinated by cardiology, and he is currently pursuing his pediatric cardiology fellowship at the same institution. Omar was touched by President Barack Obama’s speech on immigration reform, as he referred to immigrants by saying “they did not come here in search of a free ride or an easy life. They came to work, and study, and serve in our military, and above all, contribute to America’s success” (1). Omar’s goal is to leave his fingerprint on the field of pediatric cardiology, and he realizes this means a road full of obstacles that can only be overcome with persistent work.
There are 2 distinct groups of IMGs: those who were born and attended medical school in their home country, but come to practice and attain certification in the United States; and those who were born in the United States, but attended medical school abroad. Regardless of the pathway, IMGs have rapidly become an essential part of the adult and pediatric cardiovascular workforce in the United States (2). IMGs represent 37% of the physicians in internal medicine, 28% in pediatrics, and 30% of the fellowship training positions in cardiology (2–4). However, IMGs face many challenges to reach the same goals as their counterpart American medical graduates.
The first challenge for IMGs is to attain residency and fellowship positions in highly competitive academic institutions. A second very common rate-limiting factor faced by IMGs is obtaining the appropriate U.S. visa. Most IMGs come with a J-1 training visa or an H-1B work visa. In general, most universities and academic institutions will only accept the J-1 visa (although this rule has many exceptions) for medical trainees. The J-1 visa can be extended for up to 7 years; however, the trainee is required to return to his or her native country for 2 years after training completion prior to seeking re-entry into the United States for medical practice. As many IMGs often choose to stay in the United States for myriad reasons, they may preferentially search for institutions that sponsor the H-1B visa. The H-1B visa is a work visa that is valid for 6 years and does not have the same requirement for leaving the United States at the end of training. Unfortunately, many fellowship programs will not sponsor this visa, which limits the available options for IMGs.
Once training begins, IMGs can face challenges due to language barriers and cultural differences (4). As a result, some IMGs also experience isolation in the workplace, as well as a feeling of guilt for leaving their country and a need to give back to it (4). One of the largest causes of frustration for IMGs is “brain waste,” because their skills obtained prior to coming to the United States are often unrecognized, underutilized, or unutilized (3).
Below are 7 tips for IMGs (5) that may help prevent brain waste and create brain gain, without brain drain:
1. Put first things first. There are varied, complex reasons why IMGs leave their countries and decide to train in the United States. One of the reasons is the excellent training at U.S. institutions compared with their own countries. As mentioned, many U.S. institutions will only offer the J-1 visa, which has the 2-year requirement to leave after training is complete. This may discourage some excellent IMG candidates who wish to stay in the United States and give back to the profession. Under the right academic and funding settings, numerous options for waiving the J-1 visa requirement exist. These opportunities often are not realized or utilized by IMGs. As such, we suggest prioritizing the academic considerations and goals in lieu of the visa type when deciding about future cardiology training. This will prevent the brain waste that may be associated with immigration.
2. Research always helps. Research helps develop intellectual and interpersonal skills for IMGs (4). Most importantly, studies show that residents and fellows who publish in peer-reviewed journals during training are more likely to continue publishing in their future careers (6). IMGs also could help meet the demand for physician scientists in the United States (7). Unfortunately, early career academic cardiologists are facing many challenges, including increased competition and less funding opportunities (8). To identify the motivated stars, many program directors and chairmen look for research and academic productivity when selecting incumbent fellows. Fellowship programs relish trainees who bring new research ideas, experiences, and work ethic to the table. Last, presenting research at national conferences and networking with other fellows and faculty members increases the possibility of establishing the next steps in their medical careers (9).
3. Turn abstracts into papers. Completing work with publications is a very important characteristic of a great fellow. It demonstrates your self-motivation and commitment to academic medicine. In an academic institution, your research contributions are as valuable as your clinical role (10).
4. Synergize. Good mentors are critical in academic cardiology, especially for IMGs (11). Search for mentors who have some experience with mentoring IMGs, because these mentors will have a more complete understanding of our backgrounds, milestones, and expectations (12). Oftentimes, multiple mentors are better than a solitary one. Another important synergistic aspect is connecting to other fellows in different programs through the local societies, including the state chapters of the American College of Cardiology. These societies will provide opportunities to network and exchange experiences and can help locate employment when the time comes (9).
5. Seek systematic ways to give back to your own country. To overcome feelings of guilt for staying in the United States and to change the brain drain into a brain gain, giving back to your country of origin can be essential. There are many ethnic medical associations based in the United States that have activities to help your country of origin, including online training courses, scholarships for new IMGs, and health mission trips that can aid in building the health care capacity in your native countries. Additionally, helping prospective IMG students from your own country and even other countries by offering mentorship opportunities and becoming a person of contact can be extremely valuable for the newcomers, and is also personally rewarding.
6. Keep working hard. Calvin Coolidge once said, “Nothing in this world can take the place of persistence. Talent will not…. Genius will not…. Education will not…. Persistence and determination alone are omnipotent” (13). Many IMGs report that hard work was the key to their success in training, despite many barriers and failures. As the number of IMGs in the U.S. medical training programs continue to decrease with the increased number of American medical graduates, persistence and hard work become more valuable (14).
7. Sharpen the saw. Maintain balance and renew your resources and energy. Although we always recommend healthy lifestyles to our patients, we should also adhere to this recommendation (15). This will provide the long-term energy that will help maintain the drive necessary for a long, sustainable future career.
Although the available positions for IMGs within cardiology training may decrease in the future as the number of American medical graduates increases, these recommendations may help IMGs excel in a cardiology fellowship program. In essence, persistence and hard work cannot be overstated. IMGs will continue to contribute to the field of cardiology in the United States.
RESPONSE: Aim for a B-HAG
Drs. Alsaied and Madueme discuss the opportunities, challenges, and frustrations faced by international medical graduates (IMGs) pursuing a career in cardiovascular medicine in the United States. The U.S. certification process ensures that the brightest graduates of medical schools from other countries have an opportunity to obtain advanced medical training in the United States. IMGs have not only filled important manpower needs that otherwise would have significantly compromised the value of U.S. cardiovascular care, but have also undeniably had a positive, lasting effect on clinical care, medical education, and research (1). However, some have argued that by attracting medical school graduates from other nations, the United States has cannibalized the much-needed medical manpower of these “donor countries,” particularly developing nations—the so-called “brain drain” (2,3). To minimize the damage of this migration and to enhance the spirit of cooperation, the Mutual Educational and Cultural Exchange Act of 1961 established the J1-exchange visa program (4). The intent of the J1-exchange visa program is to “promote international medical education through programmatic and research activities” (4). This J1-exchange visa program is, therefore, designed neither to be a hurdle nor a pathway for legal immigration, but instead to be a program of mutual exchange between the donor countries and the United States. To minimize brain drain, the J1-exchange visa program requires individuals who seek to remain in the United States after training to obtain a certificate of waiver from their home countries and to return and serve their home countries for at least 2 years.
Despite the long-held view that the migration of doctors impoverishes the home country (2,3,5), contemporary economists suggest that migration of a country’s brightest can benefit the economy of their less wealthy homelands (6). The benefits come primarily through remittances of income, the positive effect of returning migrants, and the possibility that being able to migrate to greener pastures induces other individuals to seek more advanced education (6). Many established cardiologists have helped build or support clinical or academic infrastructure in their native countries, and others have served, started, or contributed to limited clinical care facilities in their home countries.
Finally, like other immigrants, IMGs come to the United States because of the belief that anyone can pull themselves up by their bootstraps and succeed. Successful immigrants also possess “the triple package,” which includes impulse control, a sense of superiority, and a simultaneous sense of insecurity (7). Together, these attributes result in a driven individual with “the self-belief, the discontent, and the grit” (7) to achieve success. Although there will be obstacles to overcome, many IMGs have achieved extraordinary accomplishments and have contributed not only to the vitality of the U.S. health care system, but also to global health care. In addition to Drs. Alsaied and Madueme’s recommendations, I suggest that IMGs model their pathway on successful IMGs who have preceded them and to consider having a “big hairy audacious goal” (B-HAG) (8,9). A B-HAG, a 5-, 10-, or 30-year mission statement, should be strategically and emotionally compelling. As IMGs progress through their careers and as circumstances change, these goals may have to be regularly updated to be relevant, but having a clearly defined goal at each stage will allow better focus on the future. Having an international background and U.S. training in cardiovascular sciences is a distinct advantage, particularly with burgeoning demands of global health (10,11). IMGs can leverage their backgrounds and clinical expertise to make a difference both in the United States and in their native countries.
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