Robert A. Figlin, MD, FACP: Hi, I’m Bob Figlin, the Steven Spielberg Family Chair in Hematology-Oncology at Cedars-Sinai Cancer Center in Los Angeles. I’m delighted to have Dr. Dizman join me today. Dr. Dizman is an internal medicine resident at Yale, having spent an international postdoctoral fellowship program at City of Hope, and she is off to MD Anderson Cancer Center in the fall. Congratulations and welcome, and thank you for joining us.
Nazli Dizman, MD: Thanks Dr. Figlin. It’s an honor to be here and discuss with you on these projects.
Dr. Figlin: Let’s dive into really a broad understanding of the challenges for the international medical graduate (IMG). Why did you set up the IMG program with Toni Choueiri, MD, and what are you trying to accomplish? How are you hoping that [other IMGs] can navigate the path that you are navigating successfully? What are your thoughts about that?
Dr. Dizman: Yeah, absolutely. That’s a great question. I am originally from Turkey. I completed medical school in Turkey and did residency training in Turkey. Then I came to the United States for research, and I eventually ended up planning to stay here and go through this IMG path. I did residency at Yale, which was a great opportunity for me as an IMG because it is rare. Now I’m going to a fellowship.
Along the years, I have aspired to and looked up to many oncologists who are IMGs in this space. I have seen their struggles in the past, and I [have] come across the same ones. Dr. Choueiri has been very instrumental as a mentor and sponsor along the way, [as have] many others, [such as] Charu Aggarwal, MD, MPH, Mariana Chavez Mac Gregor, MD, MSC, and so many IMGs helped out.
And last year around this time, while we were talking with Dr. Choueiri, we noticed that the American Society of Clinical Oncology (ASCO) could actually help us help other IMGs in the future. At this time, we approached ASCO, mentioning that there are several unique challenges for IMGs that are very unfamiliar territory to non-IMGs.
As a very brief overview, IMGs comprise one-third of the medical oncologists in the United States. This population serves one-third of the Americans seeking oncology care. … Although comprising really a large, substantial amount of the practitioners, they really lack support along the years, and their challenges are unknown to Americans.
Dr. Figlin: What are some of those challenges?
Dr. Dizman: I think it starts with the time point that they finish medical school in their home country and then plan to come to the United States. The first step of coming to the United States is either to find an observership, meaning observing a physician without any patient contact, doing clinical electives, or starting a research position in the United States. There are so many IMGs trying to find these positions, but we don’t have enough positions that are paid that could allow them to come to the United States.
Dr. Figlin: It’s a big challenge? The economic transition from the home country to the United States?
Dr. Dizman: It is challenging, the conversion rates between Turkey and United States are very different. It’s challenging for internationals to pay for the US Medical Licensing Examinations or come here to the United States with their own support and financial systems and start a job here. Aside from that, you really need to show to the system what you have actually done in the United States and [that you are] kind of accustomed to this system, a little bit, before you apply to residency. [That could be by] doing research or doing some clinical work with the physicians. You have to do something first.
After this, you apply to residency. Only 58% of IMGs match into residency programs in the United States. A large proportion match into non-academic programs. Then comes fellowship. Again, the rates for IMGs in the fellowship match is a little bit lower, mainly because of one of the main issues, which is visa challenges. I guess that’s probably the one that impacts from the beginning up until early years in the career.
Dr. Figlin: And was COVID a big barrier, because of the immigration status?
Dr. Dizman: Yeah. Most times, they are actually not on immigration visas, they’re on visiting [visas]. I mean, one type of visitor base-exchange visa is a J-1. That requires you to go back to your home country after finishing training in the United States for two years or to go serve in an underserved setting for a few years, so that you get that waiver. During COVID, I think that travel restriction really impacted those who wanted to come to the United States for research. Also, it really impacted the people who live in the United States and whose families are far away. They couldn’t travel, even if there was a major event.
Dr. Figlin: Do all of the IMGs want to stay in the United States or do some of them want to get trained and go back to their own countries?
Dr. Dizman: I think that is not uncommon. I had friends and colleagues who wanted to go back after getting the training in the United States. J-1 visas actually encourage that: Bringing someone in, training them, and then they have to go back to their country. There’s a big fact that United States is at the forefront of research, at the forefront of healthcare, when it is available. It is a lot more common for people to want to stay, serve here, do research, and at the same time take care of their patients.
Dr. Figlin: What would be an easier path for IMGs? I mean, clearly we do not have a sufficient American workforce for cancer care. We have a great need for IMGs. I think that we all understand that that’s value added. What could we do as a country to facilitate the best and the brightest from other countries to come and practice here, learn from us, practice with us, participate? What are some of your ideas around that?
Dr. Dizman: Yeah, that’s an excellent question. I think the problem is multilayered, and before doing any policy changes, I think we have to start taking small steps. For example, in residency fellowship programs, we have to have a better understanding of the specific challenges for IMGs. We should be able to support them while they’re advancing in their careers. In residency programs, in fellowship programs, visa issues are a big challenge. If [IMGs] really intend to stay here, J-1 doesn’t help with that. Giving them the knowledge and the details about visa situations before starting residency or right after starting residency or fellowship, and giving support through their immigration issues, is an important thing.
In general, I think we should have a good understanding that most IMGs become successful and become good physicians, and then they take care of one-third of our oncology patients right now in the United States. I think giving them a chance, opening their applications, and giving them the opportunity to shine with mentor support is the first step. I think by the time that we understand this challenge on a larger scale, in every program, and we understand the challenges and we make sure that we support them at that point, then we can talk about what the country could do.
Dr. Figlin: Thank you so much for joining me today. I think it’s important that we educate our community around the importance of an IMG. I think most people don’t know that a third of the people who take care of cancer patients are IMGs, which is a very important number. I think that training programs benefit greatly from that. Research programs benefit greatly from that. I’m not sure that Americans would go through the same thing that foreign graduates go through to come to the United States. Thank you for doing so.
Dr. Dizman: Thank you. Thanks for having me here. I appreciate this opportunity.
Dr. Figlin: Take care.
This transcript has been edited for clarity.
