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Division of Plastic/Reconstructive and Hand Surgery/Burn Surgery, Department of Surgery, University of Cincinnati College of Medicine, 231 Albert Sabin Way Suite MSB 2360A, Cincinnati, OH 45267, USA
International Medical graduates (IMGs) are an integral part of the United States health-care system and flagbearers of diversity.
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IMGs have contributed significantly to Hand Surgery in terms of skillsets, innovation, leadership, mentorship, and research.
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Numerous challenges exist for IMGs to successfully establish their practice in the United States.
Most International Medical Graduates (IMGs) are first-generation immigrants who plant the seeds of diversity not only in the health-care sector but also in the society at large. The contributions of IMGs to diversity are enormous. IMG physicians become the flag bearers of their countries in the United States, which is the “melting pot” of cultures and diversity. A patient visiting an IMG physician experiences a different accent, appearance, and culture. This broadens the perspective of the society, and encourages tolerance, understanding, and respect.
The American Academy of Family Physicians defines an IMG as a physician who received a basic medical degree from a medical school located outside the United States and Canada that is not accredited by a US accrediting body, the Liaison Committee on Medical Education (LCME), or the American Osteopathic Association.
IMGs enter the United States medical education system at different levels of training. They not only empower the system by plugging in gaps of physician shortages but also bring along inherent diversity.
However, not all IMGs are foreign nationals. American nationals who pursue their medical training abroad are also considered IMGs. Such students choose to train in a foreign country such as the ones in the Caribbean, Europe, or Asia for a multitude of reasons. Lower cost of education, exposure to different cultures, and training in international medicine are the main drivers.
Once they complete their medical education, they are also considered an IMG.
The 2 pathways for IMGs are (1) fresh IMG pursuing residency training in the United States or (2) specialist IMG pursuing fellowship training in the United States.
Journey of fresh international medical graduate getting into US residency and then fellowship
A fresh IMG is someone who recently graduated from a medical school abroad. After completing medical school in a foreign country for 4 to 5 years and passing the United States Medical Licensing Examinations, IMGs then apply for residency along with US seniors. This is followed by a lengthy process of multiple interviews culminating toward match day. The coveted residency positions are highly competitive, and it is not uncommon for IMGs to spend a year or two in research or preliminary positions to make themselves worthy of consideration. The competition to be invited for a residency interview is very fierce.
As per National Resident Matching Program (NRMP), about 5048 American IMGs applied for NRMP in 2022, of which only 3099 (or 61.4%) matched. For foreign IMGs, the number has declined further down to 58%. This is in stark contrast to US seniors with 93% matching into a residency position.
The situation gets worse in surgical specialties for IMGs. Of the 1619 categorical General Surgery positions, 1457 were given to American seniors and graduates, 80 to American IMGs and 81 to foreign IMGs. As expected, the IMGs fare worse in securing Orthopedic and Plastic Surgery positions, with 19/875 Orthopedic and 11/194 integrated Plastic Surgery positions going to IMGs.
Many IMGs end up completing multiple years of preliminary positions in hopes of matching into a categorical position. Once successful in securing a categorical position, the residents take 5 to 6 years to complete their residency. Following residency, these IMG will be board-eligible in their respective specialty and can pursue either fellowship or employment opportunities within the United States. Candidates interested in Hand Surgery apply for the Hand Surgery match hosted by the American Society for Surgery of the Hand (ASSH). There are 97 fellowship programs accepting candidates from Orthopedic, Plastic, and General Surgery backgrounds.
Specialist International Medical Graduate Pursuing Fellowship Training in the United States
Less common are IMGs who enter the US training system after completing their residency in a foreign country. These IMGs are specialists in their basic specialties and come to the United States for further training, usually for fellowship training. Although some fellowship programs are more open to international candidates, most are not. In the Hand Surgery fellowship match 2021, of the 181 positions through the Hand Surgery match, 174 went to United States and Canadian graduates, 6 to American IMGs and 1 to a foreign IMG.
To be eligible for an Accreditation Council for Graduate Medical Education (ACGME) accredited training position, The ACGME requires completion of an ACGME-accredited residency program, an AOA-approved residency program, a program with ACGME International Advanced Specialty Accreditation, or a Royal College of Physicians and Surgeons of Canada accredited, or College of Family Physicians of Canada accredited residency program located in Canada.
As most specialist IMGs are not trained from these programs, they do not qualify for an ACGME-accredited position. On rare occasion, the review committees for Orthopedic Surgery and Plastic Surgery can allow certain exceptions to the fellowship eligibility requirements for certain outstandingly qualified IMG applicants. Applicants accepted through this exception must have an evaluation of their performance by the Clinical Competency Committee within 12 weeks of matriculation.
Foreign IMGs can obtain fellowship training in positions without ACGME accreditation. In Hand Surgery, the Christine M. Kleinert Institute has a parallel international program where 6 to 8 IMGs are trained annually. This program attracts fellows from all over the world. During the past 62 years, about 1300 fellows have been trained from 58 different countries.
The fellowship training does not make the specialist IMG eligible to take US boards or the Subspeciality Certificate in Surgery of the Hand. Thus, they pursue one of the following pathways:
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Return to their home country—Most IMGs return to their home country after completing their advanced training in the United States. Many such US fellowship-trained Hand surgeons have gone on to become world leaders in Hand Surgery and have started their own centers of excellence and fellowship programs, Ganga Hospital in Coimbatore, India being one such institute that attracts Hand surgeons from all over the world.
Pursue further fellowships—Some IMGs continue seeking further training and advancing their skill set by pursuing fellowships in subspecialities of Orthopedic or Plastic Surgery.
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Start working—Rarely are IMGs able to serve patients in their capacity as specialist Hand surgeons. As these IMGs are not board eligible, they face multiple challenges in licensing and credentialing as discussed later.
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Pursue residency—Sometimes, following fellowship, the IMGs redo their residency in a basic specialty in the United States to be board-eligible. These fellows must compete with recent medical graduates to get into a residency position and restart their residency from the intern level, both very challenging and grueling circumstances.
Legacy
Despite these hardships and hurdles, many IMGs have been very successful in their career as Hand surgeons in the United States and have contributed tremendously to this field. From being Society presidents to innovators, to teachers, IMGs have made the field of Hand Surgery very rich. The authors acknowledge the struggles and contributions of all IMGs through this article; however, due to space and time constraints, we briefly highlight a few cherry-picked contributors and their contributions. A comprehensive list of IMGs and their achievements, although essential, is a daunting task. The authors wholeheartedly acknowledge this criticism.
Skillset—Dr Tsu-min Tsai, Taiwan
When Joseph Kutz attended a meeting in Japan in 1974, he saw a young microsurgeon presenting a unique case of a 4-finger replant. What made the case unique was the fact that these fingers were previously replanted a few years ago. The patient suffered amputations of the same fingers again and this microsurgeon replanted them back—a feat never achieved before! This surgeon was Tsu-min Tsai. Impressed by his microsurgery skills and determination, Harold Kleinert and Hiram Polk, the chair of surgery at University of Louisville at that time, invited him to Louisville. During his visit, Dr Tsai demonstrated a successful replantation of a ring avulsion injury considered nonsalvageable by many at that time. Realizing the need to have such a skill set in the practice, Kleinert and Kutz asked Dr Tsai to join their group.
Bringing in such a skill set translated into clinical success. The survival rate of replants increased from the prevailing 40% to 90%. A triumph Dr Tsai is “most proud of” in his professional career spanning half a century. Worth mentioning here are 2 beneficiaries of Dr Tsai’s amazing skills; the first man to walk on the moon and the man who got the most successful hand transplant to date (Fig. 1).
Fig. 1Neil Armstrong (green arrow) with his replanted finger flanked by Dr Thomas Wolff (red arrow), Dr Tsu-min Tsai (blue arrow) on the right, and Dr Joseph Kutz (yellow arrow) on his left.
Even though he is now retired, Dr Tsai continues to participate actively in teaching the fellows. His teachings go beyond medicine, and he shares the secret of his success in these words—“Never be lazy for learning, avoid bad habits and keep good health.”
Innovation: Dr Luis Scheker, Dominican Republic
“The need to solve problems leads to innovation,” says Dr Luis Scheker who has described many innovative techniques, designed a prosthetic device that bears his name, and currently owns the company that manufactures this device (Fig. 2). Dr Luis Scheker came to the United States in 1982 looking forward to spending a year in Louisville and to head back to the Dominican Republic as the first microvascular surgeon in the country. However, the “assembly line Hand Surgery” at Louisville attracted him to stay here. “People need a hand to do everything” says Dr Scheker “and that was the appeal” to switch from Craniofacial Surgery to Hand Surgery. With support from “Futuristic” Harold Kleinert, Robert Acland, and others, Dr Scheker made Louisville his home.
Fig. 2Newspaper article showcasing Dr Luis Scheker, his prosthesis, and a patient happy with her result.
For a patient with carpometacarpal arthritis, to reconstruct the intermetacarpal ligament, he designed the half flexor carpi radialis technique. Similarly, distal radioulnar joint (DRUJ) pain was an unsolved problem at the time despite the moderate success of Darrach’s procedure. In 1995, when encountered with a Vietnam veteran with a hand grenade explosion, Dr Scheker innovated a way to provide pronosupination. This innovation ultimately led to the birth of DRUJ prosthesis and the “rest is history.”
Dr Scheker advises young IMGs looking for a career in Hand Surgery to find a suitable mentor, who would advise, give ideas, and even scrub in difficult cases. He recommends that a university setting would be ideally suited at the beginning of an IMG’s career.
Leadership: Dr Neil Jones, United Kingdom
Dr Jones’s journey is as astonishing as it is unique, perhaps unparalleled. Under an exchange program between Oxford University and the Medical College of Wisconsin, Dr Jones was the first trainee to visit Milwaukee. What was supposed to be 1 year, turned out to be decades of serendipitous association between Dr Jones and American Hand Surgery.
“I had always wanted to go into one of the surgical specialties,” says Dr Jones; however, Cardiac Surgery and Transplant Surgery seemed “mundane” and Neurosurgery “depressing.” During his registrarship in Orthopedic Surgery, he found Hand Surgery “intriguing.” Another fortuitous moment occurred, when he suddenly got a call from Dr William Grabb at the University of Michigan to join their residency program in Plastic Surgery. Following his residency, Dr Jones was selected for the Hand Surgery fellowship program at the Massachusetts General Hospital in Boston, under Dr Richard Smith. “In my naivety, I asked Dr Smith if I could delay the fellowship for a year later as I really wanted to go back to England” recalls Dr Jones, “fortunately, Dr Smith agreed”; something that would be considered impossible today. Dr Jones therefore returned to England for another year of fellowship training and subsequently moved back to Boston to complete his hand fellowship. These frequent transatlantic journeys earned him a reputation that he had “designed his own training program”!
Dr Jones has occupied multiple leadership positions in the United States, including President of the American Society for Reconstructive Microsurgery 2008 to 2009 and President of the ASSH 2015 to 2016. To put this in perspective, only 6 surgeons have ever been presidents of both these prestigious organizations and 2 of them have originally been from the United Kingdom—the other being Dr Graham Lister. During his presidency, Dr Jones promoted international collaboration (Fig. 3). He announced a new ASSH International Hand Surgery fellowship program, in which 3 young US Hand surgeons would spend 3 months operating in high volume Hand Surgery centers in China and India. He also developed the ASSH International Visiting Professor program in which a senior ASSH member visits several institutions in 2 developing countries to evaluate patients and teach Hand Surgery. Finally, he instructed the program chair of the annual ASSH meeting that all symposia and instructional courses should include at least one international Hand surgeon.
Dr Jones’s advice for aspiring leaders is to work their way up within an organization, developing a local, national, and international reputation. “Take part in committee activities and show yourself to be a good team player, organizer, and communicator” says Dr Jones, “Gather respect and you will advance in leadership.”
Mentorship: Dr Milan Stevanovic, Serbia
“The mediocre teacher tells. The good teacher explains. The superior teacher demonstrates. The great teacher inspires.”—William Arthur Ward
Having mentored hundreds of medical students, residents, and fellows, Dr Milan Stevanovic has inspired many, who in turn have reached great heights making their mentor proud. Dr Stevanovic recalls one such event. While attending a talk on face transplants, Dr Stevanovic told the presenter how much he enjoyed the talk, the presenter, in turn, replied “Thank you for showing me the dissection techniques.” To Dr Stevanovic’s surprise, the presenter was a frequent attendee of his flap course and thus one of his students. Proudly recalling the meeting Dr Stevanovic says, “Teaching is an obligation. You teach and never know how much you influence.”
Two factors influenced Dr Stevanovic’s career. His math teacher and the Yugoslavian war. Being a math major, he wanted to pursue a career in electrical engineering emulating the Serbian legend, Nikola Tesla. However, his math teacher, who profoundly influenced him, directed him to take up medicine to help people. After completing his Orthopedic Surgery residency at the Medical University of Belgrade he entered the Joseph H. Boyes fellowship program, the oldest and most prestigious Hand Surgery fellowship of that time. He followed this with a microsurgery fellowship at Duke under Dr James R. Urbaniak. On his return to the University of Belgrade, he established the first microsurgery center with many firsts in the nation such as the first hand replant, toe transfer, free fibula, and so forth before the Yugoslavian civil war caused him to migrate back to the United States.
Back in the University of Southern California, Dr Stevanovic made multiple contributions such as chimeric medial thigh flap, increasing the survival of the medial skin on gracilis flap, emergency free functional muscle transfer, and has the unique distinction of performing 6-toe transfer in a single patient in 2 stages.
Dr Stevanovic (Fig. 4) advises the prospective IMGs to approach good mentors. “Good people like good people and where you are trained matters.” For the prospective mentors, he advises that selecting the right candidates is most important, “it is like selecting the government.” He prefers candidates with skills in sports/arts or literature because they have “a part of the brain that I don't have.” “Respect the student and never be angry or suppress his/her ideas. Many times, these are better than your own.”
Research is an integral part of IMG’s journey in establishing a career. One such passionate researcher who is contributing to the growth and innovation of Hand Surgery is Dr Linda Cendales. Dr Cendales is the only person in the United States to have completed formal fellowship training in both Hand and Microsurgery and Transplant Surgery. She finished her high school in Bogota, Colombia, her college in the Kingdom of Swaziland, and medical school in Mexico City, Mexico, where she opted to spend a year researching immunology and rheumatology at the National Institute of Medical Sciences.
What made her select this field? “Being passionate about one’s interests is energizing” Dr Cendales recalls this passion when she encountered a woman in her 60s with severe rheumatoid arthritis. Immunosuppression was not as developed as it is today and despite being on multiple immunosuppressive medications, she had debilitating hand deformities. “What if we give her a hand transplant?.. she is already on immunosuppression and kidney transplants are performed routinely” reasoned Dr Cendales. However, it was a time when she “did not know or had spoken with anyone who had done a hand transplant.”
“Once a challenge is identified, work hard to overcome it - by getting trained, working hard, and support from others.” Moreover, this path led her to the Christine M. Kleinert Institute, where Dr Cendales spent 2 years with Dr Warren C. Breidenbach as the principal investigator and the rest of the team to establish the nation’s first hand transplant program (Fig. 5).
Pursuing her passion, Dr Cendales became the first person to be accepted into the National Institute of Health transplant and immunobiology fellowship where she established the primate model for vascularized composite tissue allotransplantation (VCA) that has the largest reported experience in the nonhuman primates VCA to date. She also established the currently accepted classification system for rejection of skin containing VCA. Dr Cendales went on to establish 2 more hand transplant programs one at Emory University in Georgia, Atlanta, and the other at Duke in North Carolina, where she currently heads the VCA program.
“There is no substitute for hard work” is the mantra Dr Cendales passes on to the next generation. Be “prudent, persistent, patient, and persevere. Do what you do well, and people will see it,” says Dr Cendales “It is difficult to argue with a good result. Talent cannot be hidden.”
Current and Future Challenges for International Medical Graduates
IMGs face a multitude of challenges. Visa and immigration issues are common hurdles and play a crucial role in career decisions. The decision to pursue a fellowship or a job, as well as the location of the job depends on the immigration status. Currently, most IMGs receive their training on a J-1 visa sponsored by the Educational Commission for Foreign Medical Graduates. Following training, to pursue a job in the United States, they need to obtain a J-1 waiver and subsequently an H1b visa. Not all prospective employers offer such waiver positions. These waiver positions are typically located in medically underserved areas, where the physicians must serve at least 3 years.
In addition, the H1b visa has a limitation of 7 years. To immigrate to the United States, the physician will need a green card. The process to obtain a green card can be long, especially for physicians from China and India.
Another challenge for specialist IMGs is board certification. Although the IMGs who complete their residency in the United States are eligible to take their boards, those who enter through the fellowship pathway are not. Fellowship training does not allow candidates to receive board certification. Fortunately, The American Board of Plastic Surgery (ABPS), The American Board of Orthopedic Surgery (ABOS) as well as The American Board of Surgery (ABS) each have alternate pathways for board certification through an academic route.
The ABPS requires the specialist IMG to work in a division/department of Plastic Surgery that is ACGME–approved for a Plastic Surgery residency training program, as an Assistant or Associate Professor, for 7 consecutive years while being engaged in the teaching and training of Plastic Surgery residents. After attaining Associate Professorship and fulfilling several other criteria, the IMG can be deemed eligible to take the boards, contingent on the board’s decision.
The ABOS pathway is open for Orthopedic surgeons who have independently practiced for at least 5 years in the United States while serving on the full-time academic teaching faculty in a single ACGME-accredited Orthopedic Surgery residency program.
Similarly, The ABS requires that the IMG must be employed as a full-time teaching faculty member at a LCME-accredited medical school and at an institution with an ACGME-accredited General Surgery residency training program. The accreditation of both the medical school and training program must span the 5 continuous years of employment.
A third challenge is to get a state license, which is a prerequisite to working and fulfilling the above requirements. The license to practice is issued by respective state boards and this can also be a challenge for the specialist IMG due to the lack of ACGME-accredited training. The application process varies depending on the state.
It requires submission of all training materials, and frequently needs a prospective job offer and a personal appearance before the state licensing board. Often, IMGs can only obtain a limited institutional license to commence their job before subsequently getting a full unrestricted license.
In addition, even after getting a license and board certification, the fellowship-trained specialist IMG still may not be eligible to obtain the Subspecialty Certificate in Surgery of the Hand (previously known as CAQ hand). This is because, to be eligible for the Subspecialty certificate, the specialist IMG must have completed their fellowship in an ACGME-accredited position. If the fellowship was done in a nonaccredited position, the IMG is not eligible for the Subspecialty certificate. As previously discussed, not all Hand Surgery fellowship positions are ACGME-accredited positions. Even if an IMG completes an ACGME-accredited fellowship, the individual still needs board certification in basic speciality to be eligible to obtain the Subspecialty Certificate in Surgery.
Finally, becoming a member of the prestigious ASSH has its own unique set of challenges. To become an active member, the candidate must have passed the Subspeciality certificate. Although the Subspeciality certificate is not needed to become an “International member,” the candidate must reside outside the United States.
Unfortunately, the specialist IMGs practicing in the United States do not fit in either of these categories. These IMGs, even if they are board-certified via the academic route, are ineligible for ASSH membership. However, in special circumstances, exemption from the Subspeciality certificate can be obtained if two-thirds of the members of the Council determine that the individual has made extraordinary contributions to the understanding and treatment of disorders of the upper limb and/or the education and training of physicians in Hand Surgery.
The American Association for Hand Surgery (AAHS), while requiring board certification, does not require the Subspeciality certificate for its membership.
Another overlooked aspect in an IMG’s journey is family. Some IMGs enter the United States leaving behind loved ones, whereas some bring their dependents with them. Both scenarios have their own challenges. Maintaining long-distance relationships during hectic residency or fellowship training is difficult for anyone and even more so when loved ones live across the globe in a different time zone. A trip home can be expensive, and time-consuming, and returning to the United States often requires a new visa. To avoid these hassles, IMGs do not visit their home for many years. The spouses of IMG physicians are considered dependents and need special employment authorizations to work, or to obtain training. Cultural and language barriers can be challenging for children to assimilate into schools. Thus, it can be truly said that the success of an IMG stands atop the sacrifices made by the whole family.
Despite the multitude of challenges, IMGs continue to contribute to the healthcare system in the United States and to the field of Hand Surgery. From filling the gap of health-care shortage, to serving in underserved areas, and bringing in expertise, skill sets, leadership, and innovation. It will be prudent to say that Hand Surgery in the United States has greatly benefitted from the contributions of IMGs.
Disclosure
No disclosures.
References
Residency Application Requirements for International Medical Graduates. Aafp.org.
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