Alien: The Experience of a Foreign Resident
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Prepublication Release
Alien: The Experience of a Foreign Resident
Jamie Lim, MD
DOI: 10.1542/peds.2020-040576
Journal: Pediatrics
Article Type: Feature—AAP Section on Pediatric Trainees
Citation: Lim J. Alien: the experience of a foreign resident. Pediatrics. 2021; doi:
10.1542/peds.2020-040576
This is a prepublication version of an article that has undergone peer review and been accepted
for publication but is not the final version of record. This paper may be cited using the DOI and
date of access. This paper may contain information that has errors in facts, figures, and
statements, and will be corrected in the final published version. The journal is providing an early
version of this article to expedite access to this information. The American Academy of
Pediatrics, the editors, and authors are not responsible for inaccurate information and data
described in this version.
©2021 American Academy of Pediatrics
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Alien: The Experience of a Foreign Resident
Jamie Lim, MD1,2
Affiliations:
1. Boston Medical Center, Department of Pediatrics, 801 Albany St., Boston, MA
2. Boston Children’s Hospital, Department of Pediatrics, 300 Longwood Ave., Boston, MA
Corresponding Author:
Jamie Lim, MD
Department of Pediatrics, Boston Medical Center
801 Albany Street, 2nd Floor, Boston, MA 02119
Email: jamie.lim2@bmc.org
Phone: 857-272-3031
Conflict of Interest Statement: The author has no conflicts of interest relevant to this article to
disclose
Funding/Support: None
Acknowledgments
Drs. Tyler Rainer, Brenna Chase, Heather Hsu, and Sarah Wingerter for their feedback on the
essay. Drs. Catherine Michelson, Theodore Sectish, and Bob Vinci for their unwavering support.
Contributors’ Statement
Dr Lim conceptualized and wrote the manuscript and agrees to be accountable for all aspects of
this work.
©2021 American Academy of Pediatrics
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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 eleven 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. While 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 upon 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 Customs and Immigration
Services (USCIS) 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 US 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 USCIS left me without work
©2021 American Academy of Pediatrics
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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 3x5 inch piece of paper glued into my passport, which could be
stamped invalid in seconds. I am not alone. Many of my non-citizen 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
non-citizens to legally work.3,4,5 Cited as necessary to protect American workers, the policies
failed to recognize the contributions that foreigners provide across industries, including in the
healthcare field. In particular, they threatened devastating effects on foreign medical trainees like
me who rely on one of two important visa programs—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 five 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 timeline for J-1 physicians. The change had implications for the
over 12,000 residents and fellows on J-1 visas at 750 teaching hospitals across all 50 states.7
©2021 American Academy of Pediatrics
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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 over $200,000.9 Since
residents and fellows earn average salaries of $58,000-$77,000, this wage rule would make it
infeasible for training programs to afford to hire non-citizen medical school graduates.10 In 2016
alone, there were over 10,000 H-1B physicians in the United States, many of them trainees.11
Although barely acknowledged, the American healthcare 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 US after their training were also more likely than their
American colleagues to work in underserved areas, many of these positions in primary care.12
Altogether, almost a quarter of all active doctors across the nation were international medical
graduates (IMGs).13 In pediatrics specifically, IMGs made up 23.3% of all pediatricians in 2019.
Over 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 U.S. 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
©2021 American Academy of Pediatrics
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policies would affect thousands of foreign physicians whose only goal is to serve their
communities. Thus, they ultimately hurt patients—in the midst of an ongoing pandemic.
Fortunately, in part because of advocates including the AAP, these two 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 while the administration’s latest
immigration bill demonstrates a more welcoming stance towards immigrants, I urge everyone to
pay attention to its details—including around non-immigrant 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
demonstrated 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 my residency community, who make me feel valued. While
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
©2021 American Academy of Pediatrics
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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.”
References
1. Amin R, Ensor D, King J, Koppel A, Sadler B. U.S. worried about more al Qaeda attacks.
CNN. May 13, 2003. Accessed November 25, 2020.
https://www.cnn.com/2003/WORLD/meast/05/13/saudi.blast/index.html.
2. Green E. Visa Delays at Backlogged Immigration Service Strand International Students.
The New York Times. Published June 16, 2019. Accessed November 25, 2020.
https://www.nytimes.com/2019/06/16/us/politics/visas-international-students.html.
3. Executive Office of the President. Suspension of Entry of Immigrants Who Present a
Risk to the United States Labor Market During the Economic Recovery Following the
2019 Novel Coronavirus Outbreak. April 22, 2020. Accessed July 10, 2020.
https://www.federalregister.gov/documents/2020/04/27/2020-09068/suspension-of-entry-
of-immigrants-who-present-a-risk-to-the-united-states-labor-market-during-the
4. Executive Office of the President. Proclamation Suspending Entry of Aliens Who Present
a Risk to the U.S. Labor Market Following the Coronavirus Outbreak. June 22,2020.
Accessed July 10, 2020. https://trumpwhitehouse.archives.gov/presidential-
actions/proclamation-suspending-entry-aliens-present-risk-u-s-labor-market-following-
coronavirus-outbreak/.
5. Ordonez F. President Trump Extends Freeze On Many Worker Visas. National Public
Radio. December 31, 2020. Accessed January 16, 2021.
https://www.npr.org/2020/12/31/952550071/president-trump-extends-freeze-on-many-
worker-visas.
©2021 American Academy of Pediatrics
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6. Department of Homeland Security. Establishing a Fixed Time Period of Admission and
an Extension of Stay Procedure for Nonimmigrant Academic Students, Exchange
Visitors, and Representatives of Foreign Information Media. September 25, 2020.
Accessed October 25, 2020.
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time-period-of-admission-and-an-extension-of-stay-procedure-for-nonimmigrant.
7. Open Letter to USCIS Acting Regulatory Chief Sharon Hageman. October 26, 2020.
Accessed November 25, 2020. https://searchlf.ama-
assn.org/letter/documentDownload?uri=/unstructured/binary/letter/LETTERS/2020-10-
26-Duration-of-Status-Comment-Letter-FINAL.pdf.
8. Department of Labor Interim Final Rule on Computation of Prevailing Wage Levels.
American Immigrant Lawyers Association. October 8, 2020. Accessed October 25, 2020.
https://www.aila.org/advo-media/agency-liaison/submit-feedback-notices-requests-for-
comment/dol-interim-final-rule-computation-of-prevailing.
9. Robeznieks A. Judge voids rule pricing H-1B doctors out of areas that need them.
American Medical Association. December 9, 2020. Accessed January 16, 2021.
https://www.ama-assn.org/education/international-medical-education/judge-voids-rule-
pricing-h-1b-doctors-out-areas-need-them.
10. AAMC Survey of Resident/Fellow Stipends and Benefits. Association of American
Medical Colleges. Accessed March 10, 2021. https://www.aamc.org/data-
reports/students-residents/report/aamc-survey-resident/fellow-stipends-and-benefits
11. Kahn PA, Gardin TM. Distribution of Physicians With H-1B Visas By State and
Sponsoring Employer. JAMA. 2017;317(21):2235-2237.
https://jamanetwork.com/journals/jama/fullarticle/2620160
12. Mathema S. Immigrant Doctors Can Help Lower Physician Shortages in Rural America.
Center for American Progress. July 29, 2019. Accessed October 25, 2020.
https://www.americanprogress.org/issues/immigration/reports/2019/07/29/472619/immig
rant-doctors-can-help-lower-physician-shortages-rural-america/.
13. 2015 State Physician Workforce Data Book. Association of American Medical Colleges.
Accessed November 25, 2020. https://www.aamc.org/data-reports/workforce/report/state-
physician-workforce-data-report
14. Duvivier RJ, Gusic ME, Boulet JR. International Medical Graduates in the Pediatric
Workforce in the United States. Pediatrics. 2020;146(6):e2020003301.
https://pediatrics.aappublications.org/content/146/6/e2020003301
©2021 American Academy of Pediatrics
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15. Open Letter to DHS Acting Secretary Wolf. October 26, 2020. Accessed November 25,
2020. https://www.aafp.org/dam/AAFP/documents/advocacy/workforce/gme/LT-DHS-
G6-J1Visa-102620.pdf.
16. Kanno-Youngs Z. Biden Nominates Cuban-Born Lawyer to Lead Homeland Security
Department. The New York Times. November 23, 2020. Accessed November 25, 2020.
https://www.nytimes.com/2020/11/23/us/politics/biden-mayorkas-homeland-
security.html.
17. The White House Briefing Room. Fact Sheet: President Biden Sends Immigration Bill to
Congress as Part of His Commitment to Modernize our Immigration System. January 20,
2021. Accessed March 14, 2021. https://www.whitehouse.gov/briefing-room/statements-
releases/2021/01/20/fact-sheet-president-biden-sends-immigration-bill-to-congress-as-
part-of-his-commitment-to-modernize-our-immigration-system/.
©2021 American Academy of Pediatrics
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Jamie Lim
Pediatrics originally published online April 28, 2021;
Updated Information & including high resolution figures, can be found at:
Services http://pediatrics.aappublications.org/content/early/2021/04/26/peds.2020-04
0576.citation
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Jamie Lim
Pediatrics originally published online April 28, 2021;
The online version of this article, along with updated information and services, is located on
the World Wide Web at:
http://pediatrics.aappublications.org/content/early/2021/04/26/peds.2020-040576.citation
Pediatrics is the official journal of the American Academy of Pediatrics. A monthly publication, it has
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American Academy of Pediatrics, 345 Park Avenue, Itasca, Illinois, 60143. Copyright © 2021 by the
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