The Ethical Duty of Residency Programs to Support the Social Well-being of International Medical Graduates

Abstract

Photo ID 171204020 © Chormail | Dreamstime.com

Abstract

Residency programs have a responsibility for supporting the holistic well-being of the international medical graduates (IMGs) who have matched with their program. A holistic approach should include support not only in their clinical development, but also in their social and emotional growth. IMGs, especially new interns, often must navigate complex personal, professional, and cultural transitions. This paper explores how the lack of social networks outside the clinical setting impacts IMGs’ well-being, resilience, and clinical performance, with implications for patient care. Drawing on existing literature, ethical frameworks, the thematic analysis of eight IMG narrative articles, and a reflexive narrative by the author, this paper outlines key questions to guide future research. I will also offer recommendations for residency program directors to better support IMG residents through their transition into graduate medical education.

Introduction

As a patient with a complex medical history, I had a lot of time on my hands after being unable to work or walk without the need for intense and ongoing physical therapy for nearly three years. During those years of care, I interacted with several medical students and residents. I became curious about who physicians are as people, and the brief responses provided by my orthopedic surgeon were not enough due to time constraints. Even then, I knew that the scope of our appointments was to discuss progress after surgeries. He had no obligation to satisfy my curiosity, so I began turning to residents instead. I started meeting with residents outside of my healthcare system to hear their stories. At that time, I did not know the term “International Medical Graduate,” but I found that residents from other countries were the ones most willing to speak with me.

International Medical Graduates (IMGs) make up about a quarter of US residency trainees, and more than 325,000 IMGs are practicing physicians, filling critical gaps in underserved areas.^[1] The contributions that IMGs make to the US Healthcare system are laudable, but they come at a great cost. IMGs face significant personal and professional challenges throughout their career, often beginning in residency. During their first post-graduate year, they relocate to a new country while simultaneously balancing the intense demands of residency. IMGs can face challenges with cultural adjustment, language barriers, and social isolation. The loss of familiar social networks and cultural understanding increases their risk for emotional distress and burnout, which in turn can weaken their clinical performance.

Residency programs have a responsibility to support IMGs beyond their clinical development. While formal mentorship within the hospital is important, the role of social networks outside the clinical setting, including peer relationships, social integration into the community, and gaining familiarity with public places, is often overlooked. This paper argues that residency programs have an ethical obligation to actively foster these social supports to reduce isolation, improve well-being, and strengthen IMGs’ professional development.^[2]

The challenges IMGs face are not simply individual struggles; they are institutional issues. The absence of local social connections leaves many susceptible to loneliness and additional stress. These issues conflict with their need for stability. Although technology helps maintain long-distance social networks, it is not a substitute for meaningful in-person connections that build belonging.^[3]

Ultimately, supporting IMGs means moving beyond clinical mentorship to intentionally help them with cultivating relationships outside the clinical environment. Doing so is not optional; it is essential to uphold the ethical standards of medical education. Providing opportunities for IMGs to build social networks outside the healthcare system in which they work supports IMGs’ well-being and ensures high-quality patient care. This paper examines the responsibilities to support IMGs comprehensively through an ethical frame and proposes practical recommendations for residency program directors.

The Role of Social Support

Social support is a soft landing in high-stress environments. Peer and supervisor support can lower burnout and increase overall well-being.^[4] Physicians with strong social networks report fewer mental health concerns and demonstrate higher clinical performance.^[5]

For IMGs, support from residency programs is especially critical. When residency programs offer mentorship, peer networks, and IMG-focused support, residents report less emotional fatigue and greater job satisfaction.^[6] This aligns with research linking loneliness to burnout in healthcare.^[7] However, while professional support is necessary and beneficial, it does not fill the social-emotional needs in the same way that peer and other nonclinical networks can. The lack of informal, personal connections outside of work leaves IMGs vulnerable to social isolation, which professional mentorship alone cannot resolve.^[8] This persistent gap highlights the need for residency programs to foster both professional and personal social networks to truly support IMGs’ well-being.

The Social Network Theory reinforces the need for both close personal ("bonding") and broader institutional ("bridging") ties.^[9] Bonding ties refer to strong, emotionally supportive relationships, such as close friendships or familial-like connections. These types of connections provide a sense of belonging and psychological safety. Bridging ties, on the other hand, connect individuals to broader networks that offer access to resources, opportunities, and professional growth. It takes time and effort to build both kinds of networks. Residency programs need to create opportunities where IMGs feel seen, included intentionally, and supported both socially and professionally. The responsibility falls not just on the individuals to adjust and make these kinds of social networks happen, but on institutions to foster the conditions under which meaningful connections can take place.^[10]

Challenges of Geographical Relocation

Geographical relocation for residency disrupts an IMG’s established social network by physically removing them from the people, places, and culture that provide emotional support and stability. This displacement means leaving social networks that have been built over time or embedded since birth. Their sudden absence removes elements such as practical help, encouragement, and a sense of belonging that are essential during the stressful transition into residency.^[11]

After relocation, IMGs find themselves in entirely new social and cultural contexts where their usual modes of communication, social norms, and familiar community settings are no longer available. Regularly frequented local establishments such as cafés, libraries, or gyms keep people grounded, help to establish a routine, and maintain a sense of familiarity. Human beings thrive in familiar surroundings because familiarity fosters a sense of comfort and resilience. This is especially true during major life transitions.^[12]

Physical spaces that improve our well-being include informal gathering spots outside of home and work that foster social connection, belonging, and a sense of community.^[13] For IMGs, they have the potential to fill a vital gap by providing an informal way to interact with others and begin building local social networks. They offer routine and unstructured opportunities for connection that don't require cultural or professional fluency to participate. These communal spaces support emotional well-being, particularly in individuals navigating transition or isolation.^[14] Without opportunities to engage with such spaces, IMGs miss a powerful pathway to social reintegration and emotional stability during training.

The Paradox of Technology: Connected and Disconnected

Access to video calls and social media helps IMGs stay connected to family and friends. However, digital communication provides only temporary relief, and overuse of digital communication may even intensify feelings of isolation when used as a substitute for in-person social interactions. Overreliance on digital forms of communication, particularly social media, is associated with increased feelings of isolation among healthcare workers.^[15] Although digital tools provide a means to keep in touch with social networks abroad, technology keeps IMGs in a paradox of being connected but still lonely.

Everyday interactions like shared meals, warm embraces, and enjoying quality time together are experiences. They cannot be recreated virtually. IMGs are often expected to perform at the highest clinical level while quietly enduring emotional disconnection, with little to no institutional recognition of how deeply it impacts their well-being.^[16]

The Effects of Loneliness

Chronic loneliness is more than just a sad feeling; it alters the mind and body by raising stress levels, disrupting sleep, weakening the immune system, and increasing the risk of heart disease and cognitive decline.^[17] The loneliness and isolation IMGs face due to losing their trusted support system could rival the premature death rate of smoking daily.^[18]

Intersections of Social Networks, Well-being, and Patient Care

Social isolation has measurable effects on professional performance. It disrupts the ability to think, make sound choices, communicate, and collaborate effectively.^[19] Some residents who feel unsupported hesitate to ask for help or raise concerns, which can lead to clinical errors, missed learning opportunities, and poor evaluations. Social distress is not just a personal burden—it is an institutional risk.

The lack of social networks contributes to emotional exhaustion, cognitive fatigue, and a reduced sense of self-efficacy. Over time, this not only harms the physician but also compromises patient safety and quality of care. Emotional well-being is not separate from clinical competence, but rather, it sustains it. A residency culture that fails to prioritize emotional care risks both physicians and patients.^[20]

The Impact of Social Networks on Identity

The clinical setting often defines success by patient outcomes, efficiency, and productivity. It measures physicians by what they do rather than who they are. In this kind of environment, medical providers need reminders that they are human beings, not just human doings. All physicians need relationships and identities outside their clinical roles to sustain emotional health.^[21] For IMGs, rebuilding a sense of self in a new country is difficult but essential. Outside the hospital, meaningful relationships provide emotional grounding. These ties remind IMGs that they are more than their clinical productivity or board scores. They offer space for connection, humor, and vulnerability. These elements of humanity often take a back seat in the lives of those who practice medicine.^[22]

Physicians who lack personal relationships outside of work report higher levels of depersonalization, emotional exhaustion, and a diminished sense of personal accomplishment.^[23] Without spaces where they are known beyond the role of doctor, IMGs risk losing connection to their identity.

Systemic Barriers to Building Local Networks

IMGs face significant barriers when it comes to forming social networks outside the hospital. These challenges are not simply about individual adjustment or personality—they are embedded in the structure of medical training. Long work hours, fatigue, and the demands of clinical performance leave little time or energy for personal connection. While all residents experience this to some extent, IMGs face additional burdens that widen the gap between them and meaningful social integration.

The structure of residency itself is a major limiting factor. Residents regularly work extended shifts, often with inadequate sleep and limited time for recovery. This level of workload is linked to burnout, reduced empathy, and poorer health outcomes for physicians.^[24] Time outside the hospital, which could be spent resting or forming personal connections, is often consumed by responsibilities unique to IMGs.

Visa maintenance is one of the pressing issues that non-IMG residents do not have to face. IMGs on visas must manage a complex system of legal requirements that include maintaining status, renewing documents, attending consulate visits, and navigating immigration policy changes. These tasks are time-consuming, high-stakes, and mentally exhausting. Failure to comply, even unintentionally, can jeopardize their residency position or legal status.^[25] Unlike their American peers, IMGs often spend what little free time they have preparing documentation, traveling long distances for embassy appointments, or consulting with immigration lawyers.

This constant administrative burden limits IMGs’ ability to engage in social life. Even when time is technically available, emotional and mental fatigue make it difficult to invest in building new relationships. The residency system, as it currently stands, gives IMGs little opportunity to practice self-care or form new social networks.

Learning from Narratives

Eight narrative articles written by IMGs and a reflexive narrative based on my interactions with an IMG neurosurgery resident provide insight into emotional, cultural, and institutional challenges frequently overlooked in mainstream graduate medical education research. The narratives are peer-reviewed, first-person accounts published in open-access academic journals.

From the narratives, the five themes below highlight how structural and cultural forces shape IMG experiences. These themes offer a meaningful framework for connecting personal stories to the ethical obligations of residency programs, particularly in supporting IMG well-being beyond the clinical setting:

• Unseen and Unsupported


• Stress Related to Visa Requirements


• Cultural and Language Barriers


• Impact of Meaningful Connections


• Empowerment Provided by Narratives/Sharing Stories

In my experience meeting IMGs, the most profound conversation I had was with a neurosurgery resident from Southeast Asia. As we enjoyed the skyline view of Manhattan from the New Jersey side of the Hudson River, he looked at me and said, “I feel stupid.” Taken aback by this statement, I replied, “How is that even possible? You are literally training to be a brain surgeon. If you feel stupid, then there’s no hope for the rest of us.”

He said, “I feel stupid, and I don’t have a lot of friends here.”

“What about your colleagues?” I asked.

“I spend a lot of time in the hospital, so I don’t have time to make friends outside of that, and my colleagues don’t understand me. We spend hours performing surgery in the OR, and they make jokes I can’t understand. The humor is different in my culture, and I don’t want to laugh at something I don’t understand, so I don’t say anything. Then they get the wrong idea about me, and I don’t want to tell them it’s because I don’t understand. So, I feel stupid and alone. I don’t have friends at work, and I don’t have time to make friends outside of work. I rarely have a day off, and when I do, I just sleep.”

I offered to be his friend, but I lived six hours away from where I traveled to receive medical care, so naturally, we lost touch. The interaction was brief, about an hour and a half at most. Unfortunately, I never saw him again.

This conversation is a concrete example that further draws attention to social and emotional challenges faced by IMGs during residency.

The conversation I had with the neurosurgery resident reflects the same concerns raised in the literature and ethical framing of this paper. His feelings of isolation and disconnection from peers are not personal shortcomings. They point to larger structural issues in residency programs. Residency programs do not provide enough social or cultural support for IMGs. The neurosurgery IMG spoke about being in an environment where he did not feel like he could admit not understanding the jokes that were being told. He did not speak up for himself. He remained quiet instead of participating in the dialogue or asking for clarity. As a result, his colleagues misjudged him. He could not be fully himself at work. At the core of this experience is a lack of psychological safety, i.e., an inability to speak up, ask questions, or make mistakes without a fear of being judged or dismissed. It is foundational to learning, growth, and trust, especially in medicine, where the stakes are high and vulnerability is part of the process. Psychological safety is defined as a shared belief that a team environment allows for interpersonal risk-taking.^[26] For IMGs, those risks are amplified by differences in culture, training background, and the constant pressure to prove that they belong and that they are capable as physicians.^[27]

Institutional Responsibility

Without providing the necessary social support, residency programs violate two bioethical principles: beneficence and justice. To do good, residency programs and medical institutions have a duty to support the social and emotional needs of IMGs. This duty goes beyond teaching medical skills. It means creating environments where trainees feel included and supported as whole people. Institutions must recognize and address barriers like cultural differences and a lack of psychological safety that isolate IMGs and keep them from fully engaging in their training.^[28]  The duty of care includes attending to residents’ well-being because it directly affects their ability to learn and provide good patient care. When residents feel excluded or misunderstood, like the neurosurgery resident from Southeast Asia, they lack the support needed to succeed.^[29] This is not just a personal problem; it shows a system that is not doing enough.

Justice also calls for institutions to treat people fairly ─ relational justice means creating an environment where residents are respected, included, and able to safely express themselves without fear of judgment.^[30] Because institutions hold more power than any individual resident, they carry a responsibility to dismantle barriers that lead to exclusion and ensure equitable opportunities for belonging, growth, and success.

The ongoing absence of social support for IMGs is a serious problem. It harms IMG residents’ well-being and has adverse effects on patient care. Medical institutions must make social support a required part of residency training. This is essential not only for fairness, but because it’s an ethical obligation to both doctors and patients.^[31]

Program Recommendations

1. Facilitate Local Community Engagement

Host informal gatherings in popular community spaces (e.g., cafés, bookstores, community centers) to help IMG residents build local connections outside the clinical environment. These relaxed settings foster relationships that enhance well-being and prevent social isolation.

2. Build Strategic Partnerships with Cultural and Faith-Based Organizations

Partner with community associations, places of worship, and immigrant resource centers. These partnerships can connect IMGs with cultural familiarity, mentorship, and a deeper sense of belonging—factors that reduce burnout and promote retention.

3. Develop a Host Family Program

Offer an opt-in host family initiative for first-year IMGs (and spouses, where applicable). Programs like this provide informal “family-like” ties and cultural guidance, easing the transition into residency and mitigating the emotional toll of geographic displacement.

4. Establish an International Medical Graduate Peer Mentor System

Pair incoming IMG interns with senior IMG residents or attendings from similar backgrounds who can provide culturally informed support and guidance. These near-peer relationships promote confidence, reduce errors from miscommunication, and reinforce psychological safety.

5. Create a Tailored IMG Orientation and Resource Guide

Develop a resource guide for intern IMG residents that outlines:

• Local cultural norms specific to that state or region,


• Community resources and local events, and


• Tips for transitioning into a new culture.

6. Educate Leadership on Psychological Safety and Cross-Cultural Communication

Train chief residents on topics such as belonging, the effects of exclusion, and principles of psychological safety. This is critical to ensure IMGs can ask questions, admit uncertainty, and engage fully in the learning process, without the possibility of feeling unfairly judged or misunderstood.

Limitations

The narrative accounts included here cannot serve as a full representation of all IMGs in every situation. IMGs are often lumped together in research, without exploring specific demographic segments. IMGs have a broad spectrum of identities, experiences, backgrounds, and areas of clinical expertise. Additionally, this paper does not include perspectives from program directors or policymakers, who also contribute to systemic change. Their inclusion would strengthen the practical application and scope, as social support, networks, and inclusive activities vary greatly across institutions.

Additionally, many IMGs have positive training experiences, and it should be noted that there are many benefits for IMGs to train in US residency programs. The intent here is not to undermine the high professional value of these programs but rather to facilitate a discussion regarding graduate medical education. Graduate medical education should consider ways that IMGs can grow both personally and professionally, and deem social connection and support outside the clinical environment an important part of an IMG’s ability to thrive.  

Conclusion

This paper highlights how the lack of a support system beyond work elevates the risk of emotional distress, burnout, and weakened clinical performance. Social connection is a fundamental human need that should not be overlooked, and program directors must consider how to foster these connections both inside and outside the clinical environment. Addressing these challenges should not rest solely on IMGs, as institutions are uniquely positioned to move beyond a narrow clinical checklist toward a culture that affirms physician personhood and embraces the humanizing dimensions of medicine. Residency programs carry a moral responsibility, grounded in the principles of beneficence and justice, to support IMGs as whole people, not only as physicians-in-training. Supporting IMGs is not just about fairness; it is an ethical obligation to residents, patients, and the broader medical community. When providers are cared for, physicians, patients, and institutions all benefit.

-

[1] Association of American Medical Colleges, 2023

[2] Valente, 2019

[3] Scannell & Gifford, 2017

[4] Halbesleben, 2006

[5] Shanafelt et al. 2015

[6] Eze et al., 2021

[7] Smith & Koven, 2022

[8] Lee et al., 2019; Walton et al., 2018

[9] Valente, 2019

[10] Holt-Lunstad, 2018

[11] Ozcelik & Barsade, 2018; Wright et al., 2023

[12] Scannell & Gifford, 2017

[13] Oldenburg, 1999 (sometimes referred to as “third spaces”.)

[14] Jeffres et al., 2009

[15] Aydin et al. 2021; Twenge et al., 2020

[16] Eze et al., 2021; Lee et al., 2019

[17] Holt-Lunstad, 2018

[18] U.S. Department of Health and Human Services, 2023, p. 7

[19] Ozcelik & Barsade, 2018; Wright et al., 2023

[20] Meyer et al., 2017

[21] Dyrbye et al., 2017

[22] Beauchamp & Childress, 2019; Edmondson, 2019

[23] Shanafelt et al., 2015

[24] West et al., 2018; Sen et al., 2010

[25] Akbar et al., 2022

[26] Edmonds, 1999

[27] Meyer et al., 2017

[28] Beauchamp & Childress, 2019; Edmondson, 2019

[29] Dyrbye et al., 2017; Shanafelt et al., 2017

[30] Hirsch, 2012

[31] Gruppen et al., 2018; Dyrbye et al., 2020

-

This work is dedicated to the neurosurgery resident whose story is central to this paper. By now, you are likely an attending. I hope to find you one day and thank you in person. To my orthopedic surgeon, Dr. V., because of you, I strive to care for and support all physicians, including the next generation of “ortho heroes.”