https://orcid.org/0000-0003-4510-0534
To the Editor—I found Swartz and colleagues’ Call to Action regarding the urgent need to bolster the physician-scientist workforce in infectious diseases (ID) timely and compelling [1]. However, there is a noticeable absence—the potential contribution of foreign medical graduates (FMGs; non-US citizen international medical graduates) to solve, with quality, this pressing shortage; other articles on the ID physician-scientist pathway have also omitted FMGs [2, 3]. This letter presents some considerations for integrating FMGs into the ID physician-scientist pathway.
Rationale: The number of physician-scientists in the United States (US) has declined from 2011 to 2020 [4, 5], a trend mirrored by the ID physician-scientist workforce [2, 3]. FMGs could be game changers in mitigating this increasing shortage [6]. In 2004, they represented 20%–25% of all full-time faculty physicians serving as principal investigators on National Institutes of Health (NIH) research project grants [7]. Additionally, many applicants to ID fellowship programs are FMGs, ranging from one-third to one-fifth in recent years. For instance, in the 2023 Fellowship match, wherein ID fellowship positions had a low filling rate of 67% [8], FMGs constituted 21% (n = 64) of applicants to the specialty [9]. FMGs face unique barriers, so early actions may allow concerns to be identified that would facilitate recruitment of FMGs into a research track with less friction.
Prior to residency application: Many FMGs have already completed residency or fellowship programs in their home countries. Programs should collaborate with prospective FMGs to understand their motivations for seeking US training, as some aspire to pursue further research opportunities or physician-scientist careers.
At the time of residency application: Collaboration with local internal medicine programs and graduate medical education offices could facilitate offering the American Board of Internal Medicine (ABIM) Research Pathway to FMG internal medicine residency applicants interested in careers in ID research. The ABIM Research Pathway integrates research training with clinical internal medicine and its subspecialties, and is recommended for physicians intending to pursue careers in basic science or clinical research [10]. Through this pathway, an FMG interested in the physician-scientist track in ID would undergo at least 24 months of internal medicine training, 12 months of ID training, and at least 36 months of research training. Notably, this research track necessitates H-1B visa sponsorship for FMGs, incurring additional costs for sponsoring hospitals ($3000–$5000). This is in contrast to the standard J-1 visa sponsored for most residency applicants by the Educational Commission for Foreign Medical Graduates (ECFMG), which is free to training programs but requires the trainee to return to their home country for a cumulative total period of 2 years after completing training before permitting any other visa status changes for FMGs intending to work in the US (Figure 1).
Comparison of infectious diseases research career timelines between the usual foreign medical graduate pathway and the American Board of Internal Medicine Research Pathway. Abbreviations: ABIM, American Board of Internal Medicine; ECFMG, Educational Commission for Foreign Medical Graduates; FMG, foreign medical graduate; ID, infectious diseases; NIH, National Institutes of Health; US, United States.
During residency and fellowship: Collaborations could be fostered with resident FMGs interested in applying to ID and advocating for them to have protected research electives. Many internal medicine residency programs predominantly offer clinical training, potentially limiting FMGs’ access to protected research time or providing only a sparse number of elective weeks for research activities. Furthermore, fellowship programs should know about funding opportunities and their variations for FMGs. Most FMGs undergoing fellowship training possess J-1 visa status, rendering them ineligible for commonly pursued NIH grants such as the T32 or many K awards for later stages (eg, K08, K23). An exception is the NIH's K99/R00 award, which lacks a US citizenship requirement, and research mentors can support ID fellows pursuing this avenue. Non-NIH grant funding opportunities should also be considered.
After fellowship: Since most FMGs undergoing ID fellowship training hold J-1 visas sponsored by the ECFMG, they must either return to their home country for 2 years or pursue a J-1 waiver process. The Conrad-30 waiver is the most common pathway to obtain a J-1 waiver, requiring the FMG to practice in an underserved area without permitting protected research time, as the physician is mandated to allocate 100% of effort to clinical care [11, 12]. The process of obtaining a J-1 waiver is protracted (6–12 months) yet time-sensitive, given that only 30 slots are allocated per state across all specialties and are filled on a first-come, first-served basis after the application cycle starts around October each year. Research mentors should guide FMG mentees and help kickstart their research careers after the waiver period.
FMGs, with their diverse backgrounds, bring a wealth of unique perspectives, knowledge, and experiences from various parts of the world. The US has already invested significantly in their training, and their academic programs have rigorously tested and nurtured their performance. As potential ID physician-scientists, FMGs are not just a valuable asset, but a necessary one. We must recognize and harness this potential rather than letting it go to waste.
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Author notes
Potential conflicts of interest. Author certifies no potential conflicts of interest.
The author has submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Conflicts that the editors consider relevant to the content of the manuscript have been disclosed.
