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To Serve in America


In the first part of this two-part series, we examined the implications of international medical graduates (IMGs) in hospital medicine groups (November 2007, p. 1). Part 2 features stories from hospitalist IMGs as they establish themselves as professionals in their communities.

December 2005 was a tough time for Charles Onunkwo, MD, and his wife. He had been working since July 1 as a hospitalist with St. Clare’s Hospital in Wausau, a small town in central Wisconsin, and had just received alarming news. His H1-B visa transfer, filed by his immigration attorney, had been denied.

His wife’s application to change from a visitor visa to an H-4 (dependent of an H1-B visa holder) was also denied. As a result, his wife was considered “unlawfully present” in the country. Dr. Onunkwo was now “out of status,” because the Naturalization and Immigration Service (INS) did not recognize St. Clare’s as exempt from caps on the annual number of H1-B visas granted. The couple was faced with a mandatory return trip to their native Nigeria, and no guarantee that the U.S. Consulate in Lagos would grant them permission to return to the United States to work as physicians.

“It was a bad time for us,” he recalls.

I feel the skepticism, but I still treat the [patient or colleague] with the respect that they deserve. Ultimately, I just let my work do the talking. Charles Onunkwo, MD, hospitalist, St. Clare’s Hospital, Wausau, Wis.

I feel the skepticism, but I still treat the [patient or colleague] with the respect that they deserve. Ultimately, I just let my work do the talking.

Barriers and Adjustments

The obstacles faced by IMGs in obtaining visas and eventual permanent employment status have been well documented.1 For the Onunkwos, the story had a good outcome: a new immigration attorney hired by St. Clare’s was able to establish the hospital as a “cap-exempt” organization. Intervention by the staff of Rep. David R. Obey, D-Wis., allowed them to secure new H-1B visas and a return to this country.

Dr. Onunkwo and the other hospitalist IMGs attest that immigration hurdles constitute their biggest challenges.

There can be other barriers as well. Mark Dotson, senior recruiter for Cogent Healthcare in Nashville, Tenn., has encountered resistance toward IMG candidates from hospital administrators in some communities. Concerns usually relate to candidates’ ability to communicate effectively and demonstrate appropriate bedside manner. “There are also some misperceptions about some residency programs that can hinder an international medical graduate,” he says. In addition, some communities “want the doctors to reflect the makeup of the local community.” That means in a community that is 95% Caucasian, hospital administrators may be reluctant to hire a physician of color.

Dotson says attention to communication skills should be the primary goal of IMGs, and that buy-in from hospital administrators or leaders of hospital medicine groups is critical for smooth transitions. “I think some of the best physicians we have out there are doctors who are international medical graduates who see this as their life calling,” he says. “And, I think that even people in the general population understand that IMGs are extremely intelligent, and that they work extremely hard.”

As the following stories affirm, communities in remote or medically underserved areas are often welcoming of physicians who offer much-needed primary care.

Dr. Fajardo and his wife, Beverly

A Long Journey

In 1997, Emmanuel Fajardo, MD, medical director of the hospitalist program at St. Dominic-Jackson Memorial Hospital in Jackson, Miss., found himself “between the devil and the deep blue sea.” He had just been offered a chief residency position at the Meharry Medical College Affiliated Hospitals Internal Medicine residency program and was torn between accepting that job and a J-1 waiver offer in Shubuta, Miss., a federally designated Medically Underserved Area (MUSA).

He had been waiting a full year for the J-1 visa waiver, which allows IMGs to remain in the U.S. in exchange for five years of service in an MUSA. But, he also liked teaching and was attracted to the opportunity to pass on a legacy to the junior residents and incoming interns. He elected to proceed with the waiver because it offered the opportunity to “stay here in the States and to be able to practice medicine for good.”

Born in the Philippines, Dr. Fajardo says his family was wary about his locating to a remote area in Mississippi—but he wasn’t. “When I make a decision, I go for it 100%,” he says. “In everything I do I always do my best and leave the rest to God. I was very fortunate to find out that the community was very involved in and engaged with my waiver.

“Also, to my surprise, I didn’t feel discriminated against at all. They made me feel like I’m a part of the family. There is a strong sense of community here, indeed. The only problem then was, of course, being in a small town, that whatever you do, everybody knows about it.”

Although Dr. Onunkwo moved to Wausau, Wis., a small town in a predominantly white area, he says it was not difficult for him to adjust to life there. Part of the reason, he says, is that his first overseas experience was in Ireland, where he obtained a diploma in tropical medical at the Royal College of Surgeons in Dublin and practiced in a small village nearby. In addition, he and his wife were together in Wausau. “It was probably easier for both of us because we had each other,” he says.

And then there were their great neighbors, says Dr. Onunkwo. ”They made the transition seamless,” he says. “We have formed lifelong relationships with some of our neighbors in Wausau.” The strength of those relationships became apparent on Christmas Day 2005. “They really don’t know what they have done for us,” Dr. Onunkwo recalls warmly. “When we were going through our travails, they knew something was wrong, but we didn’t tell them exactly what we were going through. They made our day for us, because they just rang our bell and here they had the three-course Christmas dinner for us.”

Dr. Patel

Know Your Visas

To enter a residency program in the U.S., an IMG must pass steps one and two of the U.S. Medical Licensure Examination, then the Clinical Skills Examination. To obtain legal visitor status, most IMGs apply for:

  • J-1 visa: This is administered by the INS and allows an IMG to complete residency training at an Educational Commission for Foreign Medical Graduates-accredited program. If the IMG brings a spouse or other dependents, they usually obtain a J-2 visa. The J-1 visa carries a requirement that an IMG return to his or her native country for two years following completion of residency. Many IMGs want to remain in the country, which is why they often make use of the J-1 visa waiver.
  • J-1 visa waiver: This is a mechanism that allows IMGs to stay in the country and eventually apply for permanent status in exchange for five years of working in a medically underserved area. New post-9/11 restrictions of J-1 visas and attendant waivers have led a trend for IMGs to secure the H1-B visa.
  • H1-B visa: This allows the IMG to remain in the U.S. as long as they are employed full-time by an agency, academic institution or employer (such as a hospital) certified by the INS as exempt from immigrant caps on the annual number of H-1B visas granted. Spouses and other dependents of employed H1-B visa holders, then, obtain the H-4 visa in order to remain in the country.—GH

Prove Yourself

Dr. Onunkwo has been aware of misperceptions about his professional competency. “Depending on what part of the country you find yourself in, you need to continually prove yourself,” he says. “There is this perception, maybe due to the accent or the way you express yourself. It’s unspoken, but it’s there and you don’t need to be a rocket scientist to observe that. You need to prove that you’re good to be able to survive.”

This is easier for some than others.

“I cannot say I have experienced any barriers in that respect,” reports Gunter Kurrle, MD, lead physician with the WellStar Kennestone Hospitalist Group in Atlanta. “I’m European, like most Americans with European background, so it has not been my personal experience to encounter prejudice.” Dr. Kurrle’s journey to his present post as lead hospitalist is also atypical compared with most IMGs who come to the U.S. He initially took his foreign medical graduate examination in the late 1980s, just before the United States Medical Licensing Examination was initiated. He then returned to Germany for five years of additional training after his residency in this country. He came back to the U.S. for personal reasons (his wife is a U.S. citizen and was starting her residency training here) and found that entering hospital medicine was “a better fit than trying to start a practice on my own.”

Hemant Patel, MD, president of the American Association of Physicians of Indian Origin (AAIP), based in Oak Brook, Ill., believes discrimination toward foreign-born physicians has been greatly reduced since the early 1980s, when he entered the country. AAPI, with membership of 45,000, was founded in 1982 to offer support to IMGs from India. Physicians of Indian origin constitute the largest group of IMGs.2

“At that time, it was very difficult to obtain residency slots due to competition, and we had a lot more physicians to occupy those slots,” says Dr. Patel.

Dr. Fajardo believes the inclination to discriminate is inherent in everyone: “It’s latent, but if you give them the reason to discriminate against you, then it will manifest.” With regards to the physician-patient relationship, Dr. Fajardo reports that initially, on rare occasions, he encountered resistance from patients who were reluctant to trust their care to him because of his name (“I can’t pronounce it—are you a terrorist?”) or his looks (“You look too young to be a doctor—are you sure you can take care of me?”).

“At the end of the day, it’s very fulfilling when you hear them say, ‘Thanks a lot, doc, for getting me better,’’ says Dr. Fajardo. “I believe that it isn’t where you come from that matters; it’s what you can do.” Overall, he says, the realities of the medical profession are that “the outcome of what we do speaks for itself, and that’s what matters most.”

Dr. Onunkwo is philosophical about the initial skepticism he sometimes senses from patients and other colleagues. “I understand that people are wary of the unknown, and I think it’s just natural,” he says. “Usually, what happens in my situation is that I feel the skepticism, but I don’t do anything about it. I still treat the person with the respect that they deserve and ultimately, I just let my work do the talking. Everybody gets the same level of respect and attention that they need and nine times out of 10, before patients are done with their hospital stay, their attitudes toward me have changed.” TH

Gretchen Henkel is a frequent contributor to The Hospitalist.


  1. Leon LR Jr, Villar H, Leon CR, et al. The journey of a foreign-trained physician to a United States residency. J Am Coll Surg. 2007 Mar;204(3):486-494.
  2. Hart LG, Skillman SM, Fordyce M, et al. International medical graduate physicians in the United States: changes since 1981. Health Aff. 2007 Jul/Aug;26(4):1159-1169.

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