Masoom Desai, MD, Alexis Steinberg, MD, Fajun Wang, MD, Hana Nobleza, MD, MSCI, Deepa Malaiyandi, MD
The journey of foreign physicians in the field of neurocritical care (NCC) can be full of exciting opportunities but also unsettling setbacks. International medical graduates (IMGs) seeking post-graduate education face challenges beyond mastering the requisite clinical and technical knowledge, including recalibrating their workflow and day-to-day life to a completely new world. This venture requires adaptability, agility, and proactive strategies to succeed on both personal and professional fronts. While foreign physicians may embark on this journey to pursue training in various countries, this article focuses on the IMG experience in the United States.
The challenges that IMGs face throughout their career are unique. Although IMGs are invigorated with motivation and passion and bring diversity, unique skill sets, and clinical acumen (having worked in varied healthcare systems), there are often institutional, regional, and cultural preferences that may make IMGs a second option despite equivalent credentials to their peers. This could result from a lack of understanding of foreign medical education systems, among other reasons. Despite extensive planning, IMGs may encounter obstacles that cannot be anticipated at the time they are pursuing their program. One example is the unexpected consequence of the recent transition to ACGME accreditation for NCC training programs, which resulted in guaranteed J-1 sponsorship for matched fellowship candidates only for those matched up to 2022 (fellowship year 2022-2024). Beyond 2022 (fellowship candidates matched to 2023-2025 onwards), fellowship applicants can only apply to ACGME accredited NCC fellowship programs if they are seeking J-1 visa sponsorship. Awareness of the challenges and needs of IMGs has become essential as they are a key component of the healthcare workforce and help to defray a nationwide worker shortage.
Throughout an IMG’s career, each step has its own challenges. These can include matching into a competitive residency program, navigating a changing fellowship landscape, obtaining a first job that may have many stipulations and requirements, and finding research funding, all while working 100% clinical time. In order to be successful at each of these steps, an IMG must plan accordingly. Their initial task is to understand the requirements and eligibility for post-graduate training. Next, they need to excel and maintain consistency with outstanding work performance and social agility to stand out in a highly competitive environment. As they complete their training, an IMG fellow looking for a J-1 waiver job must apply for jobs over a year from their planned start date, far earlier than their co-fellows and before most programs know if they have available jobs. This substantially limits the pool of potential jobs they can apply for. Dedication and hard work are not enough, and IMGs must often make sacrifices such as living apart from a spouse and/or in an underserved or less competitive region.
There are also different pathways to obtaining employment, depending on an IMG’s specific visa requirements, and an IMG must have a clear understanding of their goals to help guide them. Immigration lawyers can assist in navigating the landscape and advise on the best course forward. For instance, if an IMG would like a research career and they need a J-1 waiver job, they will have to find an academic institution that will accommodate them. They may consider being on an O-visa waiver but that will not allow for future independently-funded NIH grants. Each IMG’s scenario is different and requires thoughtful analysis of all possible options.
The NCC world is small and full of IMGs who are sympathetic to this difficult process. An important resource is the advice and support that other successful IMGs in the field can provide. Good mentorship and sponsorship is crucial, whether from more senior IMGs or other advocates, and many IMGs who found success within the United States attribute it to the support of their mentors and sponsors. These mentors not only guide the fellow through this complicated process but can provide opportunities as well. They can market the fellow and advocate on their behalf to programs across the country, asking for available positions and giving the fellow a positive reference. They can even go to administration in the fellow’s home institution and advocate for the fellow to be hired as faculty if a position is available.
Within the field of NCC, the road for IMGs can be long and the climb steep, but it is not hopeless. The Neurocritical Care Society (NCS) stands with IMGs, and many of its current leaders are IMGs themselves. They have voiced support for IMGs, including early career members and those still in training. For example, NCS is working with ACGME and ECFMG on visa sponsorship for those who require a J-1 visa while pursuing NCC training. The NCS Trainee Committee also provides a variety of programs such as the annual mentorship program, research opportunities, authorship opportunities, various series and lectures on job hunting, contract negotiation and how to transition to the attending role smoothly, etc. They have even hosted virtual sessions for IMGs with a panel of attendings with unique and insightful views about navigating NCC as an IMG. NCC is diverse and inclusive, and it welcomes people from different backgrounds, cultures, and training disciplines, regardless of IMG status. Many people in the field recognize that inclusivity also breeds new ideas and opportunities for advancement.
Potential Roadblocks in the Career of an IMG in Neurocritical Care
Residency & Fellowship Match
One of the larger barriers IMGs have to overcome to be considered by competitive residency and fellowship programs is a lack of opportunities to get acquainted with the US healthcare system. As if that weren’t enough, IMGs need to quickly start defining their career path at an early stage, whether in the role of an educator, researcher, administrator, or master clinician. Unfortunately, however, research training and development for IMGs can lag behind their American Medical Graduate (AMG) peers, who often have research exposure during their medical school and residency training that can be leveraged during their fellowship. On the other hand, IMGs start their training in a new and different healthcare system that may not allow them the same opportunities to develop a research career, especially if they train in high volume or newer programs.
Finding a Suitable Job
There are several options available to IMGs as they navigate potential job opportunities, including careers in private practice, academia, and research, among others. The elephant that remains in the room is the continued need to have their visa requirements addressed while progressing along their career paths. Several options such as J-1, O-1, and national interest waivers exist, all of which forego the need for IMGs to return to their home country after completing the duration allotted by their exchange visitor sponsorship program. An H-1B visa is also possible but has its own drawbacks, including the duration of time one can train and limited availability. IMGs struggle with delays in their immigration sponsorship, limited research funding opportunities, and fewer career opportunities due to the nature of the citizenship process, as well as other issues they may encounter early in their careers. Specific to NCC is that the field is highly specialized and often does not meet the primary category for a J-1 waiver in many urban geographical areas. Early career decisions for IMGs demand preplanning, situational awareness, organizational and institutional support, sponsorship, and mentorship in order to achieve a successful outcome.
A successful research career for IMGs can often feel like an elusive endeavor. However, with appropriate organizational support, mentorship, career development opportunities, and strategic planning, IMGs can succeed as physician researchers. NCS and many other societies enable research funding opportunities which can provide early career support for IMGs in their research pursuits. However, many of these grants require protected research time, which is not possible during J-1 waiver positions. In addition, some grants exclude visa holders as part of their criteria (e.g., NIH grants). Currently, there are limited grant opportunities for IMGs who are required to be 80-100% clinical. Because of this, by the time candidates have competed their visa waiver requirements they have a less established track record compared to some of their peers, making them less competitive for future grants. This could potentially be offset by early immigration sponsorship by relevant organizations. Such an investment, though costly, could also come with a considerable reward as it helps unlock the true potential of IMGs in developing their research careers.
Cultural Competency and Emotional Intelligence
Cultural competency and high emotional intelligence are both key to an IMG’s success in the US. While IMGs bring diversity, it is important for them to become accustomed to the culture within the healthcare system and on a social and regional level, while also learning effective communication and coping strategies, conflict management, and how to empathize with a new group of patients and peers.
IMGs have unique barriers within medicine compared to AMGs. The issue of IMGs and how to ensure their success in NCC is an expansive topic. Outlined in our article are just some personal pieces of advice from the authors, which do not address the full gamut of challenges faced by IMGs. However, IMGs can and do have successful careers if they are able to navigate the various obstacles in their path. We are thankful to NCS for their advocacy on behalf of IMGs with the ABPN, ACGME, and other member boards, and we hope they will continue to champion the acceptance of IMGs in the field.