One night, I woke up in the pitch black to the deafening sound of a detonated bomb. The explosion killed dozens of people and shattered every window in our home, and in the dry heat of that disorienting night, all I sought was safety. I was 11 years old and living in Riyadh at the time, where my family had just relocated for my father’s job. That night, our quiet residential compound of mostly non-Saudi nationals was bombed by Islamic extremists against the Westernization of the country.1 Their message was clear: “We don’t want you here.”
Miraculously unharmed, we left the country within days. Although grateful for the opportunities to experience different cultures during our frequent moves, I grew distanced from my birth country, Japan. I never lived anywhere long enough to feel like I could call it home. Then, in 2010, I came to the United States for college. Maybe I would find a home here, I hoped.
Over the ensuing decade, as a foreigner, I became versed in the alphabet and number soup of visas on which my education and career would come to rely: F-1, J-1, OPT, H-1B. My visa status was a source of constant stress. The bureaucracy of the US Citizenship and Immigration Services was difficult to navigate. Worse, at every step of the way, I felt bluntly reminded of my status as deemed by the US government: officially, an “alien.”
I felt alien when I entered the United States and was interrogated by a customs official about why I was here. I felt alien when most residency programs, nervous about the implications of changing immigration policies, were unwilling to sponsor the visa I needed, separating me from my partner for years. I felt alien when processing delays at US Citizenship and Immigration Services left me without work authorization, forcing me to sit out the first weeks of intern year.2 I have an ever-present anxiety that my life here depends on a 3 × 5-in piece of paper glued into my passport, which could be stamped invalid in seconds. I am not alone. Many of my noncitizen peers have expressed similar fears, including the half dozen in my residency class alone.
In the past year, new federal policies far worsened these fears. In addition to the executive orders issued in early 2020 temporarily restricting new green cards and work visas (and recently extended through the beginning of 2021), several additional proposals jeopardized the ability of noncitizens to legally work.3–5 Cited as necessary to protect American workers, the policies failed to recognize the contributions that foreigners provide across industries, including in the health care field. In particular, they threatened devastating effects on foreign medical trainees like me who rely on 1 of 2 important visa programs, namely, the J-1 and H-1B.
The first of these proposals, which came from the Department of Homeland Security in September 2020, limited the duration of validity of certain visa classes, including the J-1 exchange visa, an important program sponsored by the Educational Commission for Foreign Medical Graduates that grants foreign physicians work authorization for the duration of a training program.6 The proposal dictated that those on J-1 visas must apply for an extension every year, with processing times taking 5 to 19 months. With residency and fellowship contracts issued only months in advance of the start of each new academic year, the proposed change created an impossible time line for J-1 physicians. The change had implications for the >12 000 residents and fellows on J-1 visas at 750 teaching hospitals across all 50 states.7
Second, the Department of Labor recently issued a new wage rule increasing the minimum salary required for those on H-1B visas.8 Under the H-1B program, the other main visa class apart from J-1 through which foreign physicians are granted work authorization, employers are allowed to hire certain “skilled” foreign workers. The new changes dictated that physicians on this visa, regardless of their level of training, be paid a minimum annual salary of >$200 000.9 Because residents and fellows earn average salaries of $58 000 to $77 000, this wage rule would make it infeasible for training programs to afford to hire noncitizen medical school graduates.10 In 2016 alone, there were >10 000 H-1B physicians in the United States, many of them trainees.11
Although barely acknowledged, the American health care system relies heavily on foreign physicians. In 2017, 15% of US medical residents were on visas, including J-1s and H-1Bs. Foreign physicians who remained in the United States after their training were also more likely than their American colleagues to work in underserved areas, with many of these positions in primary care.12 Altogether, almost one-quarter of all active doctors across the nation were international medical graduates.13 In pediatrics specifically, international medical graduates made up 23.3% of all pediatricians in 2019. Greater than three-quarters of these pediatricians were foreign and thus depended on, or found a pathway to citizenship through, one of these visa programs.14
Doctors here in the United States have privileges that others do not, including a high level of education, a livable income, and access through institutions to reliable legal aid and advice. We are far from the most vulnerable group of immigrants fighting to stay in this country. Still, these latest policies would affect thousands of foreign physicians whose only goal is to serve their communities. Thus, they ultimately hurt patients, importantly, amid an ongoing pandemic.
Fortunately, in part because of advocates including the American Academy of Pediatrics, these 2 rules have been suspended for now.9,15 But the fact remains that they are just examples of the quiet but consequential ways in which foreigners are constantly maligned and marginalized in this country. They are manifestations of a wave of xenophobic nationalism that has been growing over the past several years. From the shore, I hear louder and louder echoes of an all too familiar message that has haunted me since childhood: “We don’t want you here.”
The Biden-Harris Administration has signaled a drastically different approach to immigration through their choice of Alejandro Mayorkas to head the Department of Homeland Security, the first-ever immigrant to be nominated to this position.16 And although the administration’s latest immigration bill reveals a more welcoming stance toward immigrants, I urge everyone to pay attention to its details, including around nonimmigrant visas like the J-1 and H-1B, as it faces an uphill battle and potential changes in congress.17 We must remain wary that history has revealed that this country has been especially unkind to foreigners and immigrants in times of insecurity and economic hardship. Still, I am hopeful about upcoming change.
My other source of hope remains in my residency community, who makes me feel valued. Whereas other training programs stopped matching foreign residents with certain visa needs in the setting of the political climate around immigration, mine embraced us because of it. My program leadership understood the importance of representation, especially in this uncertain time. They knew how much it can mean to families when they tell their doctor, “We are not from here,” and their doctor can reply, “Me too.”
In that shared identity, instead of being made to feel the need to justify their presence, as I have my entire life, a different, warmer, message might come through: “We’re glad you’re here.”
I thank Drs Tyler Rainer, Brenna Chase, Heather Hsu, and Sarah Wingerter for their feedback on the article and Drs Catherine Michelson, Theodore Sectish, and Bob Vinci for their unwavering support.
Dr Lim conceptualized and wrote the manuscript, agrees to be accountable for all aspects of this work, and approved the final manuscript as submitted.
FUNDING: No external funding.
POTENTIAL CONFLICT OF INTEREST: The author has indicated he has no potential conflicts of interest to disclose.
FINANCIAL DISCLOSURE: The author has indicated he has no financial relationships relevant to this article to disclose.