“I’m sad you are leaving! But I’m sure you had your loans forgiven by coming here! So I am happy for you!”
A colleague said this upon learning I was leaving to pursue a fellowship. Her comment stung. As a non-citizen with private student loans, I don’t qualify for federal loan repayment programs. I came to work in a Federally Qualified Health Center (FQHC) because I wanted to.
Each year, a very small percentage of international students make it to the subset of U.S. medical schools that offer visa sponsorship. In 2019, among 1,890 foreign applicants, only 325 were accepted, and 272 matriculated into medical schools. This made up only about 1 percent of all enrolled medical students that year.
In 2012, after applying to almost every school that accepted international students and spending over $5,000 on application fees, I was accepted into just two programs. One offered me a 5-year position, with the extra year “designed to help international students learn English and the American culture.” After completing undergraduate studies in the U.S. and learning English since age 12, I didn’t think I needed the extra help. So I declined the offer. Soon after, I received another “congratulations” phone call from this school, informing me that after careful reconsideration, an “exception” was made for me to matriculate into the regular 4-year program with U.S. nationals. But there was one catch: I had to pay all four years of tuition fees before enrollment without financial aid options. This meant paying $200,000 all at once, not counting living expenses. The request for any student to have this amount of money ready to spend is unfair and, in the case of a non-U.S. national applicant whose student visa restricts her ability to work, simply absurd.
I elected to enroll in the Geisel School of Medicine at Dartmouth, which offered me a generous scholarship. And since my citizenship status didn’t permit me to obtain governmental loans, I was offered private loans via Dartmouth. All of these options were equally available to all students regardless of nationality. This allowed me to receive education from an Ivy League institution among brilliant students from over ten countries. Opportunities like this were so rare that all of the international students felt we had won the lottery of medical school admissions.
Although applying for residencies as an American graduate was a lot easier than as an international medical graduate, my need for visa sponsorship still made things trickier. Some of my favorite family medicine residencies didn’t offer visa support.
“Thank you for your application, but we regret to inform you that our program only accepts graduates from ACGME or AOA accredited medical schools.”
This was the first email I received from my top-choice program, a polite way to say “sorry, no foreigners.” Puzzled, I replied: “Respectfully, Dartmouth is accredited by the Accreditation Council for Graduate Medical Education.” As it turned out, the program coordinator read the first page of my application, where I answered “China” as my nationality, and assumed that I attended medical school overseas. She apologized, and after I became an intern there in 2016, we laughed about it. I went on to have an amazing experience at the Mayo Clinic: La Crosse Family Medicine Residency.
I’ve dedicated my passion to working with underserved and marginalized communities throughout my medical training. When looking for a job, I particularly wanted to work with an FQHC and found my new home in a Migrant Health Center located in eastern Washington in 2019. Today, I am proud to be immigrant-serving immigrants.
During the pandemic, there was no interest on my student loans. So I seized the opportunity to pay as much as I could each month. I said “yes” to every chance to see more patients and took on many extra calls. Meanwhile, other providers in my practice raved about their loan repayment eligibility through the National Health Service Corps, working in a rural, underserved community. With slim hope, I emailed the Dartmouth student loans office to ask if it was possible to qualify for any repayment programs. The answer was a resounding “no.”
In March 2022, I finally paid off my almost $200,000 student debt. Though it felt like a weight lifted from my shoulders, my heart felt heavy. I have almost no savings, dismal investments, and very limited personal belongings compared to my colleagues. I gloated about my accomplishment of having paid off student loans to an American colleague, who said: “Wait until you pay off your mortgage! Actually, wait until you own multiple properties!” As a young first-generation immigrant from a working-class family who didn’t benefit from any loan repayment/forgiveness, owning multiple properties or even paying off a single one seems impossible in the near future.
I acknowledge that as a physician, I am overall financially secure. However, after jumping over multiple extra hurdles to prove myself throughout my medical career, I couldn’t help but feel I have been handicapped financially compared to my non-immigrant colleagues. While others are being celebrated for bridging the healthcare gap in rural areas, I have been “punished” to a later start in life.
There is only one primary care physician for every 2,500 patients in rural America, compared to one for every 1,800 in urban regions. Foreign-born physicians are vital in many isolated, rural communities in the U.S. Offering loan repayment or forgiveness options to providers like me is not just a matter of fairness but a necessary step to mitigate provider shortage in underserved areas.
Zed Zha is a family physician.
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