Non-US International Medical Graduates in Psychiatry Training During the COVID-19 Pandemic: Challenges and Novel Solutions.

International medical graduates (IMGs) are a heterogenous group of physicians who have received their medical education outside the United States (US). IMGs are further categorized as US IMGs or non-US IMGs, depending upon the status of their citizenship or nationality. IMG psychiatrists make up a considerable proportion of the US psychiatry workforce. In 2021, from the 7943 non-US IMG applicants who submitted their rank order list, 4356 matched to a Post-Graduate Year-1 (PGY-1) position in all specialties, and 133 in psychiatry [1]. In 2021, non-US IMGs represented 10.6% of Child and Adolescent Psychiatry fellows, 19% of Consultation-Liaison Psychiatry fellows [2]. Non-US IMG psychiatrists play a unique role in the delivery of mental health services in the US especially for patients who are severely ill, publicly insured, socio-economically disadvantaged, and ethnic minorities [3]. They are also more likely to provide psychiatric care in rural settings [4].

In these past 2 years, COVID-19 has impacted the delivery of medical education and healthcare services around the world. Immigrant physicians have faced unique challenges that affected various aspects of their career, including but not limited to recruitment, training, and post-residency job opportunities. In this manuscript, we explore the unique impact of COVID-19 on training and career advancement for non-US IMG physicians, starting with a case study followed by the identification of specific pre-existing challenges which presented differently during the pandemic and required potential solutions to mitigate them (Table 1).

Table 1

Specific challenges faced by non-US IMG physicians and strategies that non-US IMG physicians and training programs can adopt to address those challenges

Challenges	Strategies to address challenges
	Non-US IMG physicians	Programs
Barriers to Entry and Uncertainty about the Future Immigration Status.	• Search proactively for positions supportive of your visa or visa-waiver status. • Seek out senior peers who have undergone a similar process. • Educate yourself about ways to navigate the state specific timeline for the waiver application. • Have a consultation with a trusted immigrantion lawyer when faced with a question regarding your visa.	• Legal resources from the Graduate Medical Education (GME) office and program-based mentorship around the visa process. • Consider opportunities to create J1-waiver faculty positions in academia. • Foster an advocacy model able to assess the impact of immigration challenges on IMGs and push for legislative actions to ease the visa process for physicians.
Travel restrictions secondary to visa-related needs	• Encourage seeking mental health support like individual or group psychotherapy to address inability to travel for prolonged time if visa restriction is a limiting factor.	• Provide resources including financial support for the legal advice regarding travel options during residency. • Allow time in the beginning of each training year to discuss travel plans and how to support that by accommodating changes in the rotation schedule accordingly.
Lack of familiarities with the clinical US experience	• Seek opportunities for telepsychiatry. Seek local opportunities for externships, observerships and/or electives. Continue engagement with non-clinical scholarly/research activities.	• Offer Telepsychiatry rotation, to allow even remote exposure to US clinical experience during the covid pandemic. • Provide moral support to allow continuous networking and involvement in national organizations. • Continue mentorship, sponsorship for junior faculty and early career psychiatrists, to learn how to advocate for oneself.
Unfamiliarity with virtual communication	• Recommend joining and participating in national organizations, such as APA, and AACAP that offer post-COVID online networking and mentorship opportunities for IMGs and virtual scientific meetings.	• Consider increasing the number of faculty reviewing and interviewing the residency applicants to allow for holistic evaluation and better virtual experience.
Acculturation and language	• Embrace your identity and accent and effectively communicate. • Participate in or initiate cultural diversity workshops in your programs.	• Foster community building and peer mentorship to address acculturation stress and provide opportunities for smooth integration into the system. • Arrange formal didactics on networking skills as part of residency curriculum.

AACAP American Academy of Child and Adolescent Psychiatry; APA American Psychiatric Association; ECFMG Educational Commission of Foreign Medical Graduates

Case Example

“Jamila is an IMG who resided with her husband Mo in Jordan, where they completed medical school in 2014. They planned to pursue psychiatry training in the US. Mo aced his United States Medical Licensing Exams (USMLE), and by the time he matched to a US residency program in 2016, Jamila delayed submitting her application to be with their infant during the first year of transition. Mo moved to the US in 2016 to start his training on a J1 visa, with Jamila and their baby to follow when he had stable housing. During that time, Jamila completed her USMLE exams in 2017 and joined a psychiatry residency program on an H1b visa. With new travel restrictions related to specific countries, the couple always felt like the proverbial sword was consistently hanging on their necks. In 2020, during the COVID-19 pandemic, Jamila secured a child psychiatry fellowship at the same institution where Mo worked on a J1 waiver position. Although her choice for a fellowship was limited by the small number of fellowship programs offering H1b visas in the same state as her spouse, the pandemic added another layer of delay in visa filing and approval times, because of which this couple had to go through a harrowing time trying to maintain their legal status.”

Challenge 1: Barriers to Entry and Uncertainty About the Future Immigration Status

Non-US IMGs navigate dual learning curves simultaneously, first as immigrants and second as residents. Very little research on the impact of visa requirements on the well-being of trainees is available [5]. For example, approximately 4028 non-USIMGs residents matched in 2019 for PGY-1 positions across disciplines who required a valid visa to work in the US. Most of these trainees needed an annual renewal of their visas, and commonly, many of them won’t leave the US during their training to avoid the risk of delayed re-entry, which can subsequently extend the duration of their training and delay their graduation date.

Additionally, every non-US IMG must be legally authorized to stay and work as an independent practitioner in the US after graduation. Unlike residency where a J1 exchange visitor visa involving the Educational Commission for Foreign Medical Education (ECFMG) is the norm, post-training employment requires the facilitation of the immigration process by the employer [6]. Before completing their training, the majority of the non-US IMG physicians must find an employer who is willing to sponsor their employment under either an H1B (employment) visa or a J1 waiver; otherwise, they may need to apply for a difficult-to-obtain O-1 visa for exceptional ability. Such employment opportunities are often limited in number, and often based in remote physician-shortage areas, forcing the physician to limit their potential at times. The J1 waiver position requires work at a medically underserved or health professional shortage area for 3 years before applying for a change in visa status. Such positions have state-specific limitations and need to be applied to by state-specific timelines. Filing for a change in legal status takes time (3–12 months), and the physician has to be mindful of such timelines, and their impact on family and career. Even prior to the pandemic, applying for a J1 waiver position and filing on time has been a significant challenge. Although J1 waiver requirements can be met through a return to the country of origin for 2 years before reapplying for a change in the visa status, for some physicians, this alternate pathway might not be a viable option.

The COVID-19 pandemic has proven to be uniquely challenging for non-US IMG applicants and physicians. In March 2020, the US Department of State suspended visa processing that impacted 4200 IMG physicians who matched to residency programs and were scheduled to start residency training in July 2020. Several organizations including American Medical Association (AMA) and American Psychiatric Association (APA) advocated for expediting the visa processing for non-US IMG physicians to support the US healthcare response during the pandemic. The AMA President stated that “the immigrant share of the healthcare workforce is roughly twice that of the national average in New York, New Jersey, and California—three of the states hardest hit so far by COVID-19” [7]. Furthermore, assumptions about restrictions on international travel in the light of socio-political and pandemic-related processes may also have dissuaded residency programs from recruiting non-US IMGs.

On the brighter side, some of those restrictions became less stringent in 2021. The newly elected Presidential administration changed the visa restriction proclamation that had previously impacted the non-US IMGs from specific countries that were on the banned list [8].

A potential solution for this challenge can be accomplished at two levels: institutional and regional. The first could involve encouraging the Educational Commission for Foreign Medical Education (ECFMG) to provide extra awareness materials and training to program directors and coordinators regarding the current process of navigating the visa sponsorship during training. Such information can be provided either according to local hospital policies or at an annual program directors’ meeting. The second aspect is to foster an advocacy model, which can assess the impact of immigration challenges for non-US IMGs and advocate for prioritized legislative actions to ease the visa process for physicians. This will not only require sustained advocacy efforts of national psychiatry organizations listed above but will also call for collaboration with other medical organizations that share similar interests.

Challenge 2: Travel Restrictions Secondary to Visa-Related Needs

Immigration from one country to another is a complex psychosocial process. In fact, one can safely state that no two stories of immigration are equal. Factors that may impact the psychological outcome of immigration include country of origin, location of migration, temporary or permanent migration, degree of choice in leaving the country of origin, possibility of revisiting home country, and the age at which immigration occurs [9]. To integrate into the new environment, some immigrants may give up part of their individuality while trying to fit in. Some trainees may suffer from other losses such as financial, during the transition to a new residence in a different country. Even more important, and often immeasurable changes in quality of life, and loss of family contact and support, are inherent to the immigration process. For those who undergo a difficult transition, the presence of a supportive team and leadership in the residency training program can help the acculturation process and reduce negative outcomes. In addition to academic stress, non-US IMGs may experience emotional struggles such as loneliness, family disruption, discrimination based on race, gender, and nationality, difficulties related to visa status, and inability to travel to a distant home due to cost and lack of time, among others [10].

During the pandemic, this process rapidly worsened as embassy offices outside the US stopped taking appointments except for emergencies as part of the pandemic regulations. This resulted in non-US IMG physicians avoiding international travel. For physicians whose families are located outside the US, it meant an inability to meet with their loved ones. In addition, non-US IMG physicians with families located in other countries had to track the trajectory of the pandemic and its impact in two different countries.

Individuals who were infected with COVID-19 experienced feelings of guilt, anxiety, and despair, in addition to physical symptoms from infection, and may require prolonged hospital stays [11]. For residents on visas, these challenges involve a strict timeline. This was further complicated by the impact on the length of time taken away, resulting in possible disruptions of the graduation cycle, and visa sponsorship.

Challenge 3: Lack of Opportunities for Clinical Experience

In the light of the COVID-19 pandemic and related restrictions, several challenges have emerged for non-US IMG applicants and trainees. Non-US IMG applicants traditionally travel to the US for US clinical experience (USCE). USCE is obtained in the form of observerships, externships, and/or electives. USCE familiarizes the non-US IMGs with the US healthcare system and is commonly cited as a preference or requirement by residency training programs. USCE also gives non-US IMGs, especially if they are non-native English speakers, an opportunity to practice their communication skills. It is a way for non-US IMGs to observe the culture and everyday vernacular used in the hospital settings in the US. Some of these opportunities, especially at places which offer residency training, can also serve as means for non-US IMG applicants to informally showcase their fund of knowledge, clinical expertise, and interpersonal competencies. Finally, USCE gives non-US IMG applicants an opportunity to seek and secure letters of recommendation (LoR) from psychiatrists working in the US. LoR are seen as a strong predictor for matching into the residency training programs [12]. However, due to the COVID-19 pandemic and associated restrictions on travel and participation in clinical activities, it has been difficult for non-US IMG applicants to participate in such experiences. Firstly, the programs should be aware of these limitations and take them into consideration when reviewing applications of non-US IMG candidates. Secondly, programs can consider creative ways of offering opportunities for remote, virtual USCE, considering sub-intern experiences, and inviting their matched IMG applicants for USCE prior to the internship start date. Psychiatry residency programs can also utilize telepsychiatry as a way of extending USCE to non-US IMGs [13].

Challenge 4: Unfamiliarity with Virtual Communication: Applicant Interviews and Clinical Activities

The recruitment cycle for the year 2020–2021 was complicated by the COVID-19 pandemic in several ways. Considering the travel limitations, the Association of American Medical Colleges (AAMC) [14] proposed the use of virtual interviews for the 2020–2021 and 2021–2022 matches. This recommendation was adopted by the majority of psychiatry residency programs across the US. The Association of Directors of Medical Student Education in Psychiatry (ADMSEP) and the American Association of Directors of Psychiatric Residency Training (AADPRT) supported the proposal and released a joint statement defining the standards around the application process for both programs and applicants to make the process fair and equitable [15]. Virtual interviewing is a relatively new concept for residency programs and its impact on recruitment outcomes is not fully studied yet. Interestingly, and despite the challenges posed by virtual recruitment, it may also be viewed as an equalizer. The traditional format of interviewing typically results in applicants incurring travel and lodging costs, which can be more pronounced and cost-prohibitive for non-US IMGs due to international travel. International travel became even more cumbersome during the pandemic, and a virtual interview format was utilized to mitigate such a disparity. Furthermore, psychiatry programs should remain mindful of ways in which recruitment of non-US IMGs may be uniquely impacted.

As mentioned above, the impact on USCE should be considered. Also, due to the growing interest of USMG applicants in psychiatry coupled with the uncertainties introduced by virtual interviewing and lack of limitations imposed by travel on scheduling, programs can expect to receive many applications. This increase in the applications of USMG applicants can cause an inadvertent de-prioritization of applications from non-US IMG applicants. Residency training programs should identify specific strategies to address these challenges such as by increasing the number of members on the admission committee who review applications. Holistic reviews by a diverse group of members can also minimize the impact of unconscious bias in this process [16]. In addition, time zone differences between the US and other countries are another important factor to consider when interviewing non-US IMG applicants. Furthermore, some non-US IMG applicants from low-middle-resourced countries (LMRCs) might have experienced difficulties in accessing a stable Internet connection. All these challenges can make for a stressful interview experience, and residency programs should stay cognizant of such aspects uniquely impacting the non-US IMG applicants interviewing and recruitment. This awareness, when coupled with strategies to mitigate stress, can help support non-US IMGs applicants. These strategies can include identifying alternate ways to connect such as through phone in case of a poor Internet connection.

Another aspect of adaptation to the virtual format that can pose challenges for non-US IMG residents is the impact on communication. With recommendations regarding social distancing and judicious use of protective personal equipment, many residency programs have been embedding telepsychiatry in their training. Telepsychiatry has also emerged as a viable mode of providing care to patients, with both patients and mental health practitioners recording positive attitudes towards it [13, 17]. Therefore, it is safe to assume that telepsychiatry will continue to exist as a mode of providing psychiatric care even when the pandemic recedes. Given this context, it is important to recognize how telepsychiatry will impact the clinical experience and training of non-US IMG residents. Navigating linguistic and cultural nuances are essential to understanding psychological theory and providing psychotherapy [18]. With telepsychiatry, just as USMG residents, non-US IMG residents can be encouraged to consider the intentional use of tone, speed, pauses, facial expressions, and body gestures to facilitate conversations. The use of reflections not only conveys active listening but can also provide opportunities to ensure mutual understanding. The faculty providing supervision to non-US IMG residents should take these challenges into consideration and develop individualized plans to meet the needs of non-US IMG residents.

Finally, many residency programs are using virtual platforms to host social events and to encourage bonding between incoming and existing trainees. Although these virtual social events can provide opportunities for safe interactions, they might not fully address the feelings of aloneness that many incoming residents encounter after relocating to a new place for residency training. For non-US IMG interns who relocate to a different country and culture, with limited or minimal relationship support (from which they can draw resilience), these feelings might be enhanced. Therefore, residency programs should consider strategies such as safe outdoor activities or activities involving smaller groups that can provide opportunities for bonding while maintaining physical distancing.

Challenge 5: Acculturation and Language

Immigration and acculturation stress often pose challenges for non-US IMGs. Relocating to a new country comes with its own set of struggles such as separation from the family of origin, financial losses, and changes in quality of life. These struggles were further accentuated by COVID-related restrictions on social activities, COVID-related losses in the country of origin, and “survivor’s guilt” upon relocating. In this setting, programs should facilitate safe team-building activities to promote cohesiveness for the incoming class and to support their integration into the existing cohort. Peer support, supervision, mentorship, and sponsorship continue to play a crucial role in the career development of a non-US IMG trainee. The feelings of loss and longing for non-US IMGs mentioned above are accentuated by COVID-19, creating an additional burden due to the paucity of prosocial activities related to the pandemic. The presence of supportive peers and leadership in the training program can help the acculturation process and transition.

As discussed, non-USIMGs face another challenge with language and culture particularly in learning psychological theory and therapy [19]. Non-USIMGs need to learn to use non-judgmental words of choice and read non-verbal language. Reading facial expressions has been difficult, especially with masks and with social distancing. Not unlike other learners, switching to a virtual model of effective communication has led to a reset in the art of virtual communication such as gestures and body language.

Conclusions and Lessons Learned from the Learners’ Experience

Non-USIMGs contribute a significant proportion of the psychiatric workforce. This article summarized common challenges faced by non-US IMGs during career transitions, and how those challenges have been accentuated during the pandemic. In addition, we set the stage for identifying and implementing tailored strategies towards supporting these physicians during such troubled times. We also discuss some interventions that can be made at both individual and organizational levels. These interventions can be personalized to alleviate the extra burden of the pandemic on immigrant trainees. We also highlight effective ways that training directors and faculty can help non-US IMGs identify and advocate for their training needs, recognize immigration-related challenges, and support their career transitions. Furthermore, we emphasize the need for developing an individualized feedback system at the very outset of training with ongoing mentorship even after completion of training.

Non-US IMGs are a highly diverse group in the US workforce and present with unique sets of strengths that contribute to their growth and development despite different immigration challenges. Understanding the unique factors that adversely affected the recruitment and relocation process during the COVID-19 pandemic is imperative and will need further research in the future. We need more studies on different strategies that will help to equip faculty with the skills required to identify individual non-USIMGs’ needs. In addition, focused future research on the impact of providing immigration resources (for both program directors and trainees) on career outcomes for non-USIMGs will help guide the direction of the next steps.