LAUSR

In their article, Dr. Kamalika Roy et al. describe the physician shortage in the United States (US) and how the current immigration system may exacerbate such shortages by limiting the scope of work of foreign medical graduates (FMGs) [1]. This opinion piece is an admirable effort to elucidate some of the barriers and challenges faced by FMGs. FMGs serve many underserved communities in the US. For example, in 2021 FMGs made up almost 40% of matched applicants in Categorical Internal Medicine programs around the country [2], many of which are located in areas severely impacted by the COVID19 pandemic. Given the significant contributions of FMGs, the authors advocate for a separate immigration pathway for physicians and the recapturing of unused immigrant visas (green cards) to redistribute them among board-certified, licensed FMGs. According to the authors, the shortand long-term solutions may help reduce physician shortage by reducing immigration backlog. I agree that this would be in my best interest and in the interest of other FMGs like myself. Working as a physician in the US has provided me with professional and personal opportunities that I may not have been able to obtain otherwise. Nonetheless, from a global and systems perspective, these suggestions may have unintended consequences that can perpetuate disparities worldwide. The vast majority of FMGs immigrate by completing their residency in the US and it is therefore important to first clarify the history and process of immigration to the US. The Educational Commission for Foreign Medical Graduates (ECFMG) was established in 1956 to validate FMGs’ medical credentials so they could pursue their training in the US [3]. Since 1974, the ECFMG has been responsible of the Exchange Visitor Sponsorship Program (EVSP), a program that sponsors FMGs with non-immigrant J-1 visas for a maximum of 7 years. To obtain such a visa, the ECFMG requests a “Statement of Need” from the trainee’s country of last legal permanent residence. This document states that the home country has high demand for that specific specialty and therefore supports US training while also requiring the applicant to return home for at least 2 years after training. In essence, the EVSP is a contract to train physicians from around the world so they can return home and create lasting impact in their communities. Therefore, for many lowand middle-income countries (LMICs), the EVSP is considered an investment in their healthcare system, where FMGs undergo graduate-level training elsewhere and return home to work. For high-income countries (HICs) like the US, this program brings young, eager, and low-pay resident physicians without having to invest in their medical education. Currently, there is no public data on the immigration status of FMG trainees in the US. It was reported by the AAMC that in 2019 there were 32,291 residents and fellows who were international medical graduates (including US and non-US citizens) [4]. Of those, about 60% are nonUS citizens, or FMGs [2]. In 2019, approximately 60% of FMGs received ECFMG J-1 visa sponsorship, while the other ~ 40% held an H1-B visa or another immigrations status [3]. Despite these rough calculations that are highly prone to error (and likely underestimate the number of J-1 visas), we can safely assume that the majority of FMGs enter the US with a J-1 exchange visitor visa. In other words, the majority of FMGs are sponsored through the EVSP with the intention to return home. The Conrad 30 Waiver Program was introduced in 1994 to further decrease the physician shortages in the US. This program allows J-1 FMGs to apply for a waiver of the 2-year foreign residence requirement in exchange of practicing medicine under an H-1B nonimmigrant status in a medically underserved area for at least 3 years. Each State can grant up to 30 waivers per year. Once granted, the FMG will transition from a J-1 visa to an H-1B visa, which can * Sebastian Suarez [email protected]