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America is increasingly dependent on foreign doctors − but their path to immigration is getting harder

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theconversation.com – Selma Hedlund, Postdoctoral Associate at Center of Forced Displacement, Boston University – 2024-09-25 07:27:50

For immigrant doctors, the path to permanent residency is fleeting and far from guaranteed.
Stefano Spicca/iStock via Getty Images

Selma Hedlund, Boston University

The COVID-19 pandemic exposed a pressing issue: The U.S. health care system is increasingly dependent on immigrant physicians, but it’s becoming harder for aspiring ones to work and settle in the U.S.

Today, 1 in 4 doctors are foreign-born, international medical graduates. Their numbers are even larger in underserved areas – essentially, low-income, more rural parts of the country where many American doctors don’t want to work.

This immigrant workforce is key to offsetting a dire physician shortage. The need for more doctors is due, in part, to America’s growing and aging population; U.S.-born doctors’ unwillingness to move to poorer and more rural areas; and U.S.-born doctors’ lack of interest in going into primary care, which can be less lucrative and prestigious than other areas of medicine.

As a result, immigrant doctors have become indispensable in hospitals and clinics across the nation. But while they’re in demand, more and more foreign doctors are starting to see the immigration process as a risky endeavor.

During the COVID-19 pandemic, I wrote my dissertation about how immigrant physicians navigate the U.S. immigration system and foreign licensing procedures. My interviewees described how a combination of stricter immigration policies and more competition for residency spots have made the U.S. a less feasible destination.

Visa vicissitudes

U.S. visas can be categorized into two categories: immigrant and nonimmigrant. Nonimmigrant visas, such as tourist, student or exchange visitors visas, prohibit holders from having what’s called “immigrant intent,” meaning that they don’t plan to use their visas to permanently stay in the U.S.

In order for immigrant doctors to be licensed to practice in the U.S., they need to complete licensing exams. They also need to obtain clinical experience in the U.S. This can be completed while on a tourist visa or a student visa, which are relatively easy to obtain.

However, all immigrant physicians – even if they’re certified specialists in their home country – need to get accepted into and complete a U.S. residency program in order to practice in the U.S. as specialists. These are intensive, supervised training programs that can last up to seven years.

Nonetheless, a majority of immigrant doctors in the U.S. will complete their American residencies on nonimmigrant visas, even though by this point in the process they quite clearly have immigrant intent.

It wasn’t always this way.

There’s a special work visa called the H-1B that allows for both immigrant and nonimmigrant intent. A few decades ago, many immigrant physicians entered residency programs that sponsored H-1B visas, which served as stepping stones to green cards.

But drastic restrictions to the number of people admitted into this visa program, coupled with cuts in graduate medical education funding, have directed most foreign-born doctors to what’s called a J-1 exchange visitors visa.

Challenges of working in underserved areas

The J-1 not only explicitly prohibits immigration intent, it also requires that doctors return to their home country for at least two years upon completing American residency training.

Foreign-born doctors nonetheless pursue the J-1 because there’s the opportunity to obtain a waiver, with limited slots that will allow them to remain in the U.S. and adjust to an H-1B visa. If selected for the waiver program, they must commit to a minimum of three years of service in a designated medically underserved area in the U.S.

A small group of people march holding handmade signs that read 'Save Rural Hospitals.'
Through a special waiver, immigrant doctors can work at rural hospitals that are underfunded and understaffed.
Brendan Smialowski/AFP via Getty Images

While this system can offer short-term relief to physician shortages, it can also lead to exploitation.

As one interviewee told me, “We hear very scary things about the J-1 waiver. The employers can take advantage and make you work more and pay less.”

For the duration of the waiver program, immigrant physicians have minimal ability to change employers without violating the conditions of the waiver – and their path to immigration. Underserved areas are often understaffed and underresourced, which can make for stressful working conditions.

Forced to go above and beyond

The challenges don’t end with the visa process. There are financial burdens as well.

International medical graduates often spend tens of thousands of dollars to pay for U.S. medical licensing exams, multiple visa applications, international travel and lodging, residency and green card applications.

They also spend months in unpaid positions in hospital settings to gain the U.S. clinical experience that’s required to apply for residency. Then, in order to match into residency, immigrant physicians typically need to outperform their American peers on exams. They also need to have more prestigious research qualifications and stronger recommendation letters. Still, immigrant doctors are more likely to match into less competitive residency programs.

While interviewing immigrant physicians, many testified to the competition getting steeper in recent years.

“I told a friend, if you don’t have scores in upper 90s in all the exams and you’re not a green card holder, don’t even bother,” an Indian physician who immigrated 20 years ago explained to me. “It’s so tough.”

Stuck in limbo

Over the course of my research I noticed a trend: Many international medical graduates will come to the U.S. on student visas to pursue U.S. graduate degrees in health-related fields, such as public health, before they even start the licensing process. This helps them get their foot in the door into a very complicated immigration system and build a stronger resume as they prepare for residency applications. It’s also another expensive investment.

But even those who match into and complete residency won’t necessarily be able to stay and work in America.

Those with positive experiences from working in underserved communities often struggle to remain in their positions after their waiver contracts are fulfilled because of the green card backlog.

The average immigrant’s wait time for a green card has doubled since the national quota system was introduced in the early 1990s.

By 2018, an applicant had to wait an average of 18 months to get approved for their green card and another five years and eight months to receive it. The COVID-19 pandemic introduced new barriers and delays.

Indians, one of the biggest nationalities among immigrant physicians, have the longest wait times under the current system, sometimes waiting up to a decade to obtain the security of permanent residence. Among the 1.8 million cases currently stuck in the employment-based green card backlog, 63% are Indian nationals.

A pending green card application is often formally considered abandoned if the applicant leaves the country, preventing people from visiting loved ones abroad for years.

No fix on the horizon

Despite frequent calls for change and reform, these bottlenecks continue to adversely affect both patients and doctors.

While the current model has its benefits, it also reflects a trend in which much-needed immigrant professionals live in prolonged, demoralizing uncertainty. Work visas have been subject to increasing cuts and restrictions in recent years under both the Trump and Biden administrations. Conditions will likely worsen if Trump returns to office: The “Muslim ban” he enacted in 2017 adversely affected many immigrant doctors and their patients, and his calls for increased vetting will likely exacerbate existing barriers to legal immigration.

A paradox has emerged: While the U.S. says it wants to attract and retain world class talent, its byzantine immigration system continually discourages potential hires.

The doctors I interviewed gave a variety of reasons for wanting to work in the U.S., including better lifestyles and opportunities for professional development. But the complexity and sheer unwieldiness of the U.S. visa regime is causing the nation to lose skilled professionals to other countries with more streamlined processes.The Conversation

Selma Hedlund, Postdoctoral Associate at Center of Forced Displacement, Boston University

This article is republished from The Conversation under a Creative Commons license. Read the original article.

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Feeling political distress? Here are coping strategies a psychologist shares with his clients

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theconversation.com – Jeremy P. Shapiro, Adjunct Assistant Professor of Psychological Sciences, Case Western Reserve University – 2025-01-22 07:40:00

The polarized political climate is reflected in what drives some people to therapy.
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Jeremy P. Shapiro, Case Western Reserve University

I began practicing psychotherapy during the Reagan administration. Thirty years went by before distress about politics became a clinical issue for any of my clients.

I remember the moment it first happened: There was a long voicemail from a distraught woman requesting therapy for anxiety and depression in reaction to the 2016 presidential election of Donald Trump. I listened twice to make sure I hadn’t missed something. I hadn’t. There were no other issues. This woman wanted therapy for political distress.

That was a new one for me and every therapist I knew. But now I see no sign of this clinical challenge abating.

Political polarization in the U.S. is at the highest level ever measured. Growing majorities of both Republicans and Democrats say they consider members of the other party to be unintelligent, dishonest and immoral.

What I’m calling political distress is a bipartisan mental health problem. It is based on a belief that, because the country is in the hands of bad leaders, awful things might happen. Many people experience intense fear about what the other side might do. Both Republicans and Democrats have experienced this anguish, but it peaks at different times for the two parties, depending on who won the last election.

We psychotherapists like to base our interventions on research-based strategies that have been vetted in clinical trials or, if not that, at least strategies grounded in the clinical expertise of master therapists who wrote classic books. There’s none of that for how to deal with political distress.

But therapists cannot tell a client in distress that future research is needed before we can help. Instead, we pull from what is known about how best to handle related issues. Here’s the advice I’m sharing with my clients who are upset about the way the world is going.

Taking a longer view

Information about American history is relevant to political distress because, psychologically, people evaluate their situations by comparing them with anchors or norms. You compare current dangers and threats with what you’ve faced and survived in the past.

A Democrat comparing today’s United States with the country a decade ago may feel gloomy. But broader comparisons can produce a more grounded, calming perspective.

black and white picture of dozens of men in suits and hats lined up on a city street corner
The Great Depression in the 1930s came with massive unemployment; here, thousands of people in New York line up in hopes of a job.
UPI/Bettmann Archive via Getty Images

The U.S. has faced major trials and tribulations over the course of its history. The country has proven itself to be a resilient democracy. Basic information about the Civil War, the Great Depression and World War II yields a sense that the present political moment is not the only perilous time our republic has ever faced.

Wisdom of the Serenity Prayer

God, grant me the serenity to accept the things I cannot change, the courage to change the things I can, and the wisdom to know the difference.

bronze-colored token with serenity prayer engraved on it
Change what you can, recognize what you can’t.
Jerry ‘Woody’/Wikimedia Commons, CC BY-SA

The Serenity Prayer is an effective summary of research on coping. As I discuss in my book “Finding Goldilocks,” the well-known invocation identifies two basic strategies and tells you when to use which one. People need the strength to change what can be changed and the serenity to accept what cannot. Political distress, like many stressors, calls for a combination of both tactics.

Doing what you can means funneling political anxiety into political actions, including voting, volunteering, donating money and serving as a poll worker. Can one person’s actions make a difference? They can make one person’s worth of difference. You can’t do everything, but you can do something.

In addition, taking action about a problem, even if it does not produce a solution, often reduces distress, especially if it brings you together with like-minded people.

Once you’ve done what you can, it’s important to acknowledge how much is beyond your control: The whole world doesn’t rest on your shoulders alone. Then you can in good conscience turn your attention to the good things in your own personal life.

It helps to limit your consumption of political news; past a certain point, you’re not learning anything new and just fueling your agitation.

man with head in hands with a big scribble over his head
Imagining the worst can be a first step toward moving past anxiety.
rob dobi/Moment via Getty Images

The best things in life aren’t political

One basic tool of cognitive therapy for anxiety is asking the question, “What is the worst thing that could plausibly happen?” The purpose of this question is not to get anxious people thinking about worst-case scenarios – they’re doing that already – but to move their thought process forward to a picture of how they could survive their worst fear. This is a strangely effective form of reassurance.

Democrats believe Donald Trump’s second administration will hurt people. But with important exceptions – such as undocumented immigrants who could be deported – when many people try to picture exactly how their lives will be damaged in specific, concrete, serious ways, they usually do not come up with much.

This does not mean nothing bad will happen. It does mean you likely can cope with whatever does. While Trump’s policies might be unfortunate and even infuriating for those on the other side of the aisle, they are unlikely to be disastrous on an immediate, day-to-day level for large groups of people.

A very broad perspective will remind you that democracy is a rarity in world history. For most of civilization, people have lived in monarchies or tyrannies of some sort, and most of them managed to be OK.

I’m not suggesting that people disengage from the political world. I believe it’s important to stand up for what you believe is right. My advice is not to put on your rose-colored glasses and withdraw into your own safe space, the rest of the world be damned.

But the main sources of human well-being are family, friends, meaningful work, hobbies, the arts, nature, spirituality and acts of kindness. None of these depend on political systems. We can cope with political distress by falling back on the best things in life.The Conversation

Jeremy P. Shapiro, Adjunct Assistant Professor of Psychological Sciences, Case Western Reserve University

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I’m an economist. Here’s why I’m worried the California insurance crisis could triggerbroader financial instability

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theconversation.com – Gary W. Yohe, Huffington Foundation Professor of Economics and Environmental Studies, Wesleyan University – 2025-01-21 07:42:00

Gary W. Yohe, Wesleyan University

The devastating wildfires in Los Angeles have made one threat very clear: Climate change is undermining the insurance systems American homeowners rely on to protect themselves from catastrophes. This breakdown is starting to become painfully clear as families and communities struggle to rebuild.

But another threat remains less recognized: This collapse could pose a threat to the stability of financial markets well beyond the scope of the fires.

It’s been widely accepted for more than a decade that humanity has three choices when it comes to responding to climate risks: adapt, abate or suffer. As an expert in economics and the environment, I know that some degree of suffering is inevitable — after all, humans have already raised the average global temperature by 1.6 degrees Celsius, or 2.9 degrees Fahrenheit. That’s why it’s so important to have functioning insurance markets.

While insurance companies are often cast as villains, when the system works well, insurers play an important role in improving social welfare. When an insurer sets premiums that accurately reflect and communicate risk — what economists call “actuarially fair insurance” — that helps people share risk efficiently, leaving every individual safer and society better off.

But the scale and intensity of the Southern California fires — linked in part to climate change, including record-high global temperatures in 2023 and again in 2024 — has brought a big problem into focus: In a world impacted by increasing climate risk, traditional insurance models no longer apply.

How climate change broke insurance

Historically, the insurance system has worked by relying on experts who study records of past events to estimate how likely it is that a covered event might happen. They then use this information to determine how much to charge a given policyholder. This is called “pricing the risk.”

Many California wildfire survivors face insurance struggles, as this ABC News report shows.

When Americans try to borrow money to buy a home, they expect that mortgage lenders will make them purchase and maintain a certain level of homeowners insurance coverage, even if they chose to self-insure against unlikely additional losses. But thanks to climate change, risks are increasingly difficult to measure, and costs are increasingly catastrophic. It seems clear to me that a new paradigm is needed.

California provided the beginnings of such a paradigm with its Fair Access to Insurance program, known as FAIR. When it was created in 1968, its authors expected that it would provide insurance coverage for the few owners who were unable to get normal policies because they faced special risks from exposure to unusual weather and local climates.

But the program’s coverage is capped at US$500,000 per property – well below the losses that thousands of Los Angeles residents are experiencing right now. Total losses from the wildfires’ first week alone are estimated to exceed $250 billion.

How insurance could break the economy

This state of affairs isn’t just dangerous for homeowners and communities — it could create widespread financial instability. And it’s not just me making this point. For the past several years, central bankers at home and abroad have raised similar concerns. So let’s talk about the risks of large-scale financial contagion.

Anyone who remembers the Great Recession of 2007-2009 knows that seemingly localized problems can snowball.

In that event, the value of opaque bundles of real estate derivatives collapsed from artificial and unsustainable highs, leaving millions of mortgages around the U.S. “underwater.” These properties were no longer valued above owners’ mortgage liabilities, so their best choice was simply to walk away from the obligation to make their monthly payments.

Lenders were forced to foreclose, often at an enormous loss, and the collapse of real estate markets across the U.S. created a global recession that affected financial stability around the world.

Forewarned by that experience, the U.S. Federal Reserve Board wrote in 2020 that “features of climate change can also increase financial system vulnerabilities.” The central bank noted that uncertainty and disagreement about climate risks can lead to sudden declines in asset values, leaving people and businesses vulnerable.

At that time, the Fed had a specific climate-based example of a not-implausible contagion in mind – global risks from sudden large increases in global sea level rise over something like 20 years. A collapse of the West Antarctic Ice Sheet could create such an event, and coastlines around the world would not have enough time to adapt.

In a 2020 press conference, Federal Reserve Chair Jerome Powell discusses climate change and financial stability.

The Fed now has another scenario to consider – one that’s not hypothetical.

It recently put U.S. banks through “stress tests” to gauge their vulnerability to climate risks. In these exercises, the Fed asked member banks to respond to hypothetical but not-implausible climate-based contagion scenarios that would threaten the stability of the entire system.

We will now see if the plans borne of those stress tests can work in the face of enormous wildfires burning throughout an urban area that’s also a financial, cultural and entertainment center of the world.The Conversation

Gary W. Yohe, Huffington Foundation Professor of Economics and Environmental Studies, Wesleyan University

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How nonprofits pitch in before, during and after disasters strike

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theconversation.com – Vanessa Crossgrove Fry, Associate Research Faculty/Interim Director, Boise State University – 2025-01-21 07:41:00

Social Border Grill delivers food as part of World Central Kitchen relief efforts at an Eaton Fire temporary shelter in Pasadena, Calif., on Jan. 9, 2025.
Kirby Lee/Getty Images

Vanessa Crossgrove Fry, Boise State University

Los Angeles is reeling after fires of historic proportions raced through many communities in January 2025, destroying thousands of homes. The Conversation U.S. asked Vanessa Crossgrove Fry, an associate research professor and director of the Idaho Policy Institute at Boise State University, and an expert on sustainable management and nonprofit administration, to explain what role nonprofits can play in staving off disasters and dealing with them when and after they occur.

What’s the role of nonprofits when disasters strike?

They play a critical role by complementing government efforts and filling gaps in immediate and long-term recovery needs.

Collaboration is a hallmark of how nonprofits respond to disasters. These organizations often work alongside government agencies and private sector partners in coordinated efforts. This approach ensures that aid is distributed efficiently, directing resources where they are needed most.

Often, national groups lead efforts to establish emergency shelters, distribute food and water, and offer mental health support. In a best-case scenario, these large organizations partner with local nonprofits that are uniquely positioned to mobilize quickly, leveraging their deep understanding of community needs and established trust with residents.

In some disasters, especially large ones like the Lahaina, Hawaii, fire in 2023, nonprofits also act as coordinators. They make sure that volunteers, donations and other resources flow to people who need help.

Nonprofits’ flexibility and community-based networks enable them to respond to local challenges, such as supporting displaced families or addressing unmet needs in underserved areas. Beyond immediate relief, many nonprofits remain involved in long-term recovery efforts, assisting with rebuilding homes, restoring livelihoods and fostering community resilience.

Two women sit at a table crowded with food, but look desolate.
While surrounded by food donations, Evangeline Balintona, left, and her sister Elsie Rosales, sit inside a hotel-condo after they both lost homes in Lahaina to the wildfire, Sept. 1, 2023, in Kahana, Hawaii.
AP Photo/Marco Garcia

What do nonprofits do before disasters occur?

Nonprofits play a crucial role in disaster preparedness by working to reduce risks and build resilience.

In fire-prone regions like the Los Angeles foothills, organizations often focus on educating the public, helping residents understand fire risks and creating evacuation plans. They also implement fire mitigation strategies, such as spreading awareness about the importance of clearing brush and replacing wooden roofs.

Nonprofits also run community training programs, such as CPR certification or Community Emergency Response Team – CERT – training, or Sound the Alarm events to empower residents to respond effectively during emergencies.

With CERT training, a local fire department might equip volunteers to prepare for the hazards they’re likely to face in their communities. That kind of exercise empowers them with essential disaster-response skills, including fire safety and light search and rescue know-how. During Sound the Alarm events, smoke detectors are installed in vulnerable communities and residents get help creating evacuation plans.

Partnerships with government agencies, private companies and other nonprofits should ideally be in place before a disaster occurs to ensure a coordinated response when the time comes.

For example, nonprofits may establish agreements about setting up emergency shelters or accessing and distributing food supplies. They also build networks to ensure vulnerable populations – such as low-income residents, people experiencing homelessness, and those with disabilities – are included in disaster planning and response efforts.

Other roles include advocating for more funding for disaster preparedness and infrastructure, like wildfire-resistant construction or community-wide firebreaks – areas of cleared vegetation.

In some cases, nonprofits may help coordinate the use of government resources. For instance, Idaho Department of Insurance Director Dean Cameron recently drafted a bill that’s pending in the Idaho Legislature that would provide funding for homeowners to make fire mitigation upgrades on their property.

Additionally, nonprofits often develop detailed contingency plans for their own operations so they can continue to deliver services during a crisis.

Through these proactive measures, nonprofits help communities prepare for the worst while fostering resilience that can temper the long-term impacts of disasters.

What does the situation in LA have in common with what happens in Idaho?

Los Angeles and Idaho might seem worlds apart, but when it comes to handling disasters like wildfires, they face surprisingly similar challenges.

Both places grapple with dry seasons, rising temperatures and increasing invasive vegetation that amplify wildfire risks. Climate change is exacerbating these conditions, making fires more frequent and intense.

In Los Angeles, urban sprawl has expanded development into fire-prone areas, known as the wildland-urban interface. Similarly, Idaho has seen increased development in the wildland-urban interface surrounding Boise – where the population is surging.

This type of growth poses significant risks to both homes and lives as seen in Idaho’s 2016 Table Rock Fire and the more recent 2024 Valley Fire.

In addition, wildfires in Idaho’s forested and rural areas put not only people and infrastructure at risk, but can impact valuable grazing land, as occurred in the 2024 Wapiti Fire.

In both regions, balancing the demand for housing with the need for fire-resilient planning and mitigation measures is a critical challenge.

Another shared concern for nonprofits in Idaho and California is ensuring that vulnerable populations receive enough support during and after disasters. In both urban and rural settings, people experiencing homelessness, low-income families, and those in remote areas may have a lot of trouble evacuating, accessing resources and rebuilding after disasters.

Firefighters spray down the rubble of burned homes.
A firefighter from Idaho sprays down the rubble of homes demolished by the Eaton Fire in Altadena, Calif., on Jan. 15, 2025.
Photo by Frederic J. Brown/AFP via Getty Images

What are some common misconceptions about nonprofits in disasters?

Many people tend to think that nonprofits only provide immediate relief, such as food, shelter or medical care. While these services are critical in the early stages of a disaster, many nonprofits also focus on long-term recovery and rebuilding efforts.

Nonprofits may help communities rebuild homes, restore livelihoods or address emotional trauma months – or even years – after a disaster occurs.

There is also a tendency to overlook the role of local nonprofits. High-profile national organizations often command the public’s attention, but local nonprofits are often better positioned to address community-specific needs and work directly with vulnerable populations.

These misunderstandings can lead to the underfunding – and underappreciation – of local nonprofits.

Should people still donate to established organizations?

There are more ways to give to people experiencing a crisis than there used to be.

You might hesitate to donate to large nonprofits after a big disaster like the Los Angeles fires, for several reasons. Maybe you’re concerned about transparency or the group’s effectiveness. It might feel less personal to you than giving money, say, to a GoFundMe campaign.

I think that people should still consider donating to large and established organizations, but I also believe that it’s important to do so thoughtfully. Large nonprofits, such as the American Red Cross or Salvation Army, often have the infrastructure, expertise and logistical capacity to mobilize quickly and scale their operations to address disasters effectively.

These organizations also maintain established relationships with government agencies, local nonprofits and international partners. Those networks facilitate coordinated responses that smaller or newer groups might struggle to achieve.

However, the emergence of giving options, such as crowdfunding platforms, grassroots campaigns and community-based nonprofits, has expanded opportunities for individuals to direct their support to specific causes or populations. These avenues can make a big difference, particularly when donors want to address local or niche needs. Still, newer or less established groups may lack transparency or accountability.

Established organizations tend to have robust financial oversight and accountability systems in place. They are often better equipped to address not only immediate relief needs but also long-term recovery efforts, which smaller or informal groups may not have the capacity to support.

To be sure, it’s always wise to do some research before giving money to a cause of any kind.

Ultimately, the choice depends on your own priorities. Do you want to support immediate relief, contribute to systemic solutions or help a specific community?

By donating to both large organizations and local efforts alike, you can maximize your impact and help ensure everyone in a community gets support. And that’s important, especially after a disaster as big as the Los Angeles wildfires.The Conversation

Vanessa Crossgrove Fry, Associate Research Faculty/Interim Director, Boise State University

This article is republished from The Conversation under a Creative Commons license. Read the original article.

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