The term international medical graduate or IMG, here in the United States (US), applies to those who are applying for a higher medical training in the US but did not graduate from a US medical school. I am an IMG. After completing my medical school from Nepal, I am now in the US with the determination of pursuing my further training in internal medicine here.

A large portion of IMGs is made of graduates from poor countries. There has always been a debate on how justifiable it is for rich countries to accept graduates from poor countries into their health system, especially when there is a dearth of doctors in poorer countries. Poor countries invest huge amounts of money, by their standards, to create doctors. For these governments, it is a futile investment if these investments end up leaving the country.

A few weeks ago, I came across an interesting poll on doc2doc, “Should rich countries pay ‘transfer fees’ if they poach health professionals from poorer countries?” Although I answered yes, I do not think that is the solution. Paying the poor countries will not give them back the doctor they just lost and it will only justify this transfer. I guess the issue is more about fulfilling the need for doctors in the health care system of poor countries than about financial loss or gain.

On this note, I wonder how we should view the clustering of doctors in and around major cities in a country like Nepal when people in the remote areas have to walk for days to reach the nearest doctor. Clearly, their presence in the cities is superfluous in terms of providing health care. And then, there is another group of doctors whose fees can only be afforded by the financial elites of the society. Many of these doctors in the cities, and also those with expensive fees, studied in government funding as well. Although they did not leave the country, can they still be considered as a futile investment?

The issues are more complex than they seem. One of the reasons for this is that people are more than just investments. We are individuals bundled with emotions, dreams, and interests. I am not trying to justify, in any way, doctors leaving their countries. Nothing can justify it. I understand the implications of leaving my country. I am laying down my perspectives in an honest attempt to understand why I, myself, made that decision.

For me the single most important reason to take the decision to leave my country for further education was my interest in clinical research. I had to struggle a lot to even get a brief taste of clinical research during my medical training. I do not wish to remain under privileged in that aspect during my further training now. I believe that post graduate training is the ultimate opportunity to indulge myself into clinical research. Unfortunately, this is not the case with post graduate medical education in Nepal. 

My mentor, Dr. Buddha Basnyat, often says that Nepal has a huge potential for clinical research (Read about Dr. Buddha Basnyat’s and my say on mentoring in a recent Student BMJ article ). I agree with him. I hope he will agree with me when I say there are, however, very few opportunities to learn how to do research during post graduate training in Nepal. I highlight the word learn in the sense that there are very few doctors in academic institutions in Nepal who have the experience, knowledge, or willingness to guide or encourage a trainee into clinical research.

Other aspects probably contributed as well. Corruption, poor work environment, inappropriate political influence, weak governance, to name a few. I could write pages on each of these and how they influence our decisions in the long run. But that’s beyond the point for now.

The journey as an IMG is not an easy one either. It is fraught with many obstacles at each step. I have already spent thousands of dollars to be in the US and take the US medical licensing exams. The cost of living in the US for months is beyond my financial capabilities. I have been lucky in this regard that I have found refuge in the home of two kind and caring seniors from my med school.

Not all of the IMGs get what they come here for. The programs are ruthless in their selection. They do not usually prefer to have IMGs because of the visa issues and the relative newness of IMGs to the US health care system. An IMG has to be extraordinarily better to be picked over an American graduate. Each year, only around half of the IMG applicants get into a residency program. The other half will have to return back to their countries or apply another year. 

So, here I am, starting on a totally new journey as an IMG. The days ahead seem to be tough and unclear. I will blog on how things go for me and my fellow IMGs. I’d be interested in your thoughts on doctors leaving their countries and about IMGs.

Siddhartha Yadav is a former BMJ Clegg Scholar