International Medical Graduate

This past cycle, 9% of the participants in the Ophthalmology Residency SF Match were International Medical Graduates (IMGs), who matched at a rate of 28% (for comparison, the rate was 85% for US Allopathic Seniors).  This is a statistic that I glanced over when the data was released, but admittedly have not given this group much consideration until recently.  I would like to share parts of an email conversation I had with one of those 72% of unmatched IMGs that has really opened my eyes.  I hope it does the same for you.

The italicized excerpts from this conversation are kept anonymous, but published with permission.

I very much enjoyed reading your blog on UK website, especially your article on how applicants are selected for interviews. I found your article very informative, systematic and transparent. At the same time, I found it thought/questions-provoking as a I reflected on my experience participating in the match cycle, for the 3rd time now. I am writing you this email hoping you would share with me your input on the special case of applicants who are international medical graduates (IMGs).

An International Medical Graduate (IMG) is defined as a physician that graduated from a medical school outside of the United States and Canada, including US citizens and permanent residents who complete medical school outside of the US and foreign nationals that enter the US for residency and fellowship training.  As of 2015, IMGs represent ¼ of all trainees and practicing physicians in the US.  The numbers in ophthalmology are noticeably lower:   5% of residents and 7% of practicing ophthalmologists.

Let me first briefly share my background; I earned my MD degree from [International University], moved to the US in 2016 and completed a 2-year master’s in clinical research at [Well Known US Academic Medical Center], followed by a prelim year at [Second Well Known US Academic Medical Center], and most recently, joined the [Third Well Known US Academic Medical Center] as an imaging research fellow. My USMLE step scores are: 256, 237 and Pass for step 1, step 2 CK and step 2 CS, respectively. I have letters of recommendations from mentors in the US who I worked closely with for 2+ years. I have 10+ publications/abstracts. I am on F1 student visa.

Prior to entry to the US, IMGs are carefully evaluated by the Educational Commission on Foreign Medical Graduates (ECFMG).   IMGs who are not either US citizens or permanent residents almost always complete their training on a J-1 visa, sponsored through the ECFMG at no cost to the training institution.  The vetting process sometimes can be delayed for multiple months pending security clearance, which can lead to delays in training and even loss of residency positions. The J1 program requires holders to return to their country of citizenship for at least 2 years after completion of training.  

A notable exception to this requirement is local, state and federal programs that allow IMGs to remain in the US if they work in an underserved community.  For example, the Conrad 30 federal program offers waivers to up to 35 IMGs per state per year, provided they commit to 3 years working in a medically underserved community.  Other programs include the Delta Regional Authority, Appalachian Regional Commission and Department of Veterans Affairs.

For this and other reasons, IMGs disproportionately work in rural and low-income urban communities compared to US medical graduates, serving as the primary source of healthcare access in these areas. Increasing federal immigration restrictions coupled with projected physician workforce shortfalls raise significant concerns about current and future healthcare opportunities in these vulnerable communities.

A final option for IMGs wishing to remain in the US after training is to apply for a hardship and persecution waiver, which requires “evidence that the applicant would be subjected to persecution on account of race, religion, or political opinion, on returning to the home country.”  The estimated processing time of this waiver is currently 11-14 months.

So, why do foreign graduates seek training in the US?  For many of the same reasons as the rest of us, such as financial opportunities, professional development afforded by our training system, and to improve career options.  There are others as well, including personal relationships that necessitate living in the US, or to seek asylum because of war, natural disasters, and persecution.  I’ll address some of the barriers these physicians face after arriving in the US in an upcoming post, but want to emphasize that there are refugee and international physicians currently living among us working as janitors, taxi or rideshare drivers, or in the hospitality industry, for example.  The under or unemployment of IMGs is all the more underscored by the estimated shortage of 52,000 primary care physicians in the US within the next five years, although the accuracy of all physician workforce data is limited.  Unlike other nations such as the United Kingdom, Sweden, and Turkey that have recognized the need for additional healthcare providers and the benefits of assisting IMGs with securing training positions and integrating into the healthcare system, the United States has been very slow to consider changes to its current process.


Immigration is a polarizing and popular topic (always has been), and likely to play an even more prominent role in upcoming elections.  It is intimately tied to political and personal conversations and I cannot ignore it is in the background of this one.  I will mostly side-step this issue, but do want to end this blog post with a powerful poem and perspective written by the British, Somali poet Warsan Shire:

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