Hospitalist IMGs in the pandemic

Concerns about visas and residency add to pressures of hospitalist practice.

Many of the hospitalists preparing community hospitals to face the COVID-19 pandemic face an additional challenge: their lack of permanent residency or citizenship in the U.S.

“The community hospitalists or rural hospitalists are mostly international physicians, physicians on a J-1 or a H-1B visa. The majority of the physicians are from countries of backlog that have been waiting for permanent residency for many years, like myself; this will be my 10th year on a work permit,” said Varun Malayala, MD, FACP, chair of medicine at Bayhealth Sussex Campus in Milford, Del.

Sixty-nine percent of international medical graduate (IMG) physicians practicing on visas were working in rural areas, according to a recent survey by Dr. Malayala and colleagues. Their analysis, which was accepted as a poster at Internal Medicine Meeting 2020, included 1,232 physicians, almost all of whom reported that their visa status affected their career options.

It's become standard for physicians from populous countries like India to face waits of a decade or more for permanent residency status. The Society of Hospital Medicine recently estimated in a letter to Congress that more than 10,000 physicians are caught in the green card backlog.

“Because of the way that the immigration system is designed, there is an arbitrary cap on how many permanent residencies can be issued to certain countries in a given year. And, surprisingly, it's equally allocated. It's like saying that Wisconsin and North Dakota should have the same number of electoral votes as California and New York,” said ACP Member Atul Bali, MD, a nephrologist and chair of medicine at a community hospital in Farmville, Va. “This has been a long-standing problem.”

However, the COVID-19 crisis brings some new twists. “Health care workers, whether it's a physician, nurse, or any other medical staff, whether they are on H-1B or whether they're a citizen, they're most scared about the family and the repercussions that COVID can cause in the process of trying to help other people. The problems just get worse for a physician who is on a visa,” said ACP Member Ramesh Adhikari, MD, a hospitalist in Lafayette, Ind.

Physicians working on visas are not eligible for Medicaid or Social Security benefits, if they become disabled, and the legal residency of their entire families is often attached to their jobs. “I am really worried about the families that have dependents,” said Simran Kaur Matta, MD, an intensivist at Bayhealth Sussex Campus in Milford, Del. “If the doctor, God forbid, dies, the family would be deported, because they were on the doctor's dependent visa. And that is so unfair to the family and so tragic.”

Another concern of the IMG physicians are the legal limits on their ability to help out during the crisis. Dr. Malayala described how hospitalists in his area are getting daily calls from recruiters asking them to come work in New York City hospitals, which those on visas have to decline, because their permission to work is tied to their specific employers.

“I'm three hours away, and I cannot go there and help out these folks,” he said. “If I'm off I'm sitting at home. I cannot do telehealth and help out. I cannot go to any other hospital and help out.”

Dr. Matta noted that the rules only allow her to practice at one of her hospital's two campuses. “I cannot even go to the other campus. That's how restrictive this is,” she said. “Everybody's talking about ... we're going to build so many hospitals and we're going to turn the parking garage into a hospital. We're going to bring these hospital ships and everything. The question is how you're going to staff these hospitals?”

In an April 2019 letter, ACP called on U.S. Customs and Immigration Services to reduce the green card backlog, noting that IMGs “serve an integral role in the delivery of health care” and “contribute essential care to underserved populations in the United States.” In response to the pandemic, the College expanded that request in a March 26 letter, asking the State Department to permit medical residents and physicians on J-1 and H-1B visas to be redeployed as needed.

Some IMG advocates have been lobbying the government for an additional step of issuing emergency green cards, which would provide these physicians with greater protections in addition to the ability to go where they're needed.

“I've been in this country for over a decade. I am passionate about medicine. I love the community that I serve, that I call home. It's an unprecedented time, so the country needs every health care provider to work at their full potential,” said Dr. Adhikari. “Facing the worst pandemic of our lifetime, it's for America to decide how to treat physicians in the front lines supporting the rural and medically underserved communities.”