A few years ago, my rural town expected the addition of a “J-1,” or foreign, physician. This addition was meant to alleviate the work of my father, who had been the only neurologist at our underserved hospital for the past few years. And yet, with this J-1’s arrival, my father and his office soon found themselves struggling with more work than ever before.
As many rural physicians can attest, this behavior is nothing new. Typically, J-1 physicians are required to return and practice in their home country for two years. However, to address the physician shortage in rural areas, American legislation has implemented the J-1 work exemption, which allows foreign physicians to instead work in an underserved area and remain in the States. As a result, rural hospitals often host many foreign physicians, who in return are intended to provide much-needed essential health care services.
After the required two years, the new physician at my local hospital chose to move to an urban area, leaving behind a struggling health care system in no better shape than when they first arrived. Many foreign physicians do the same, due to a lack of support and community. While this phenomenon is certainly not the fault of the individual physician, stories like my father’s demonstrate to us that the J-1 work exemption is an unsustainable fix for a far greater problem. Although the work exemption’s intention is to help address a mounting physician shortage, we must also consider the implications of such actions beyond simply providing more physicians to the areas in need.
Whenever a physician enters a new health care system, they are required to adapt to a different set of standards. Cleveland Clinic CEO Toby Cosgrove writes that when entering a new hospital, foreign doctors “must accept new organizational structures, ways of working, payment models, and performance goals.” This process of familiarization is even more difficult for foreign physicians, who, in addition to typical onboarding difficulties, may not be comfortable with the standardized curriculum taught by AAMC medical schools or the intricacies of how U.S. medical offices are run. As a result, significant effort must be made to accommodate the new physician to an unfamiliar work environment, which becomes valuable time wasted if the physician leaves a few years later, as so many have been shown to do.
Along with issues onboarding, patients in rural areas are unable to develop long-term relationships with J-1 work exemption physicians. This inability hurts both patient and provider, as both rely on forming long-term connections to create better diagnoses and treatment plans. Although it is difficult to quantify, most professionals agree that long-term physician-patient relationships can result in “better control of chronic conditions, fewer visits to the emergency department and hospital stays, and healthier outcomes.” This level of care can only be achieved through multiple years of established trust and mutual care, which cannot come from temporary J-1 physicians.
Most importantly, foreign doctors face difficulties immersing themselves within rural communities. My father, one of the few J-1 physicians who remained at the rural hospital he first worked in, endured years before he was able to feel like a true member of the local community. Even now, he still faces instances of discrimination from the very patients he attempts to treat. Racial and ethnic minorities make up only 22 percent of rural populations, compared to 44 percent of urban populations. In the face of this statistic, immigrants tend to avoid rural areas for fear of “standing out.”
Although foreign physicians may not hold the exact same fears as other immigrants, being forced into a rural community holds consequences for these doctors that urban areas do not possess. In rural areas, foreign physicians may feel alone and ostracized due to language barriers, suspicion of outsiders, and unfortunately, various forms of prejudice and intolerance. In response, the physician feels a conflicting pressure to care for an unknown community they themselves do not hold any allegiance to. A detachment forms between doctor and patient, ultimately compromising the quality of care and benefitting no one.
Instead of using J-1 work exemptions, we may look to alternative solutions to address physician shortages and health inequity. These solutions, such as reducing the cost of medical school to improve accessibility or including payment incentives, are not novel, but are crucial in their necessity.
We must establish accredited medical schools in rural areas, bolstering the sheer number of physicians and directing them towards where they are sorely needed. As we have seen in multiple university towns already, the presence of a medical school provides teaching opportunities and increased health care and creates a thriving community around the school. By aiding the accessibility of medical education in rural areas, we should encourage the idea of the “homegrown doctor” — a physician who grows up, studies, and practices medicine in a single area, and uniquely understands the health care needs of their specific community. By alleviating the nationwide physician shortage in this way, J-1’s will thus have the freedom to practice where they are best suited, and health care as a whole will be improved.
We cannot push foreign physicians towards rural medicine immediately upon their arrival to the U.S. Rather, they should be given the freedom to practice where they would best acclimate, and only later may they be encouraged to practice in underserved areas. The nationwide physician shortage is critical, but using J-1 work exemptions to funnel foreign physicians to rural areas is an unsustainable and imperfect fix. It must be addressed as we constantly seek to improve American health care.
This essay is cited in the KevinMD record on immigration and medicine.
Gregory Tan is a premedical student.
Image credit: Shutterstock.com
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