At Home in the Heartland

“Congratulations on the wedding! Indian weddings look so fun! You MUST show me the photos!” I smiled and pulled up the album on my phone to show my patient—a smiling middle-aged woman, who was on her fourth follow-up visit with me in the ID clinic. Over the past few months, she had become one of my favorite clinic patients and I, her favorite physician. The small pop-up sticky note in her electronic chart read “Will only see Dr. Sheth.” Her crinkly eyes lit up with curiosity as they glanced at the screen. “May I scroll?” I nodded and watched her face as her thumb swiped across the phone screen. My brain, after almost a decade of living in the United States, was primed. I steeled myself expectantly against an incoming microaggression. Instead, she pointed to a particular photo of me and said, “That dress is beautiful. Is that called a sari? I hope you and your husband enjoyed the event.” My mind faltered and I felt a twinge of shame at the reflex, the anticipation of an incoming insensitive or ignorant comment. I watched as she checked out at the front desk, mollifying my conscience and blaming my cynicism on burnout. Blaming my hypervigilance on sleep deprivation. This would mark my fifth year practicing in small-town America. It was also my second year at my J-1 waiver job, which is an exemption granted by the United States government to physicians who trained on a J-1 exchange scholar visa practicing medicine in underserved areas in exchange for an H1-B work visa. When people outside of my hospital learn where I work, the first question they often ask is “Wow, what's that like? Do you feel safe?” I have also had some well-intentioned individuals ask if I have ever faced racial bias or prejudice. I want to tell them about this encounter, and about how I have been the recipient of the celebrated Midwestern kindness. I want to tell them about the couple who got me Edible Arrangements after a long course of IV antibiotics, just because I had mentioned that I had never tried the famed fruit baskets. I also want to laugh with them about the gratefully ecstatic patient who called the clinic after finally having a normal bowel movement just to thank me—her “transplant surgeon”—for arranging a rather expensive fecal microbiota transplant for her recurrent Clostridioides difficile infection. To celebrate, she went to the gas station Indian restaurant—a rare delicacy in our small town—and tried Indian food for the first time. The risk, I was told, was worth it. Stories like these are why I stay, but the system that brought me here is under threat. As an international medical graduate (IMG), I came to the US as an “exchange scholar,” planning to take what I learned back to my home country. But in the end, I found friends here, created a family, and learned a lot more than I had anticipated in the most unexpected ways. IMGs like me are vital to the American healthcare workforce. They have helped to bridge gaps in access to care, especially in rural areas. In the 2025 Fellowship Match, almost 28% of matched ID fellows were non-US citizen IMGs [1]. Yet, limited resources exist to support these physicians. In addition, since 2025, sweeping immigration upheavals have threatened their legal presence in the US, affecting their already tenuous positions. An application fee of $100 000 was introduced for H1-B visas, potentially imposing a steep fine on critical access hospitals that are already struggling to stay afloat after Medicaid funding cuts [2, 3]. Immigrant resident physicians have been intimidated and detained by authorities [4]. These physicians were released later, but only after massive public backlash [5, 6]. These policy changes have caused significant confusion and stress for physicians navigating the already convoluted and bureaucratic US immigration system. It has forced us to make difficult decisions like restricting travel plans, missing important family events back home, and being unable to visit aging parents because of the fear that the lives and careers we built could be lost in an instant. These hostile conditions would push physicians like me out of this country, and some would argue that it was the entire point. So I ask them: without my position as one of only three ID physicians in the county, how much farther would my patients have to travel to see a specialist? What happens when these physicians are pushed out? Rural America will have to bear the loss incurred by these half-measure policies. Critical access hospitals stand to lose HIV physicians, antimicrobial stewards, infection prevention and public health experts—the same ones that carried them during the COVID19 pandemic. Without a simultaneous increase in medical schools or number of residency positions, there are limited solutions to the physician shortage and access issues. Introducing barriers for immigrant physicians to simply survive in the US is going to cut off these communities from desperately needed physicians and erode a vital social and cultural exchange. As an immigrant physician, my waiver job has provided me exactly that, and more. If we are serious about taking care of these communities, then it also requires taking care of the people who serve them. The J-1 waiver program has managed to bring physicians to the places that need them most and these places have continued to give them a reason to stay. Without this job, I would never have been invited by my patient to play pickleball at the Y with the sexagenarian crowd or have the slightest inclination to learn euchre so I can tell that older couple all about it at their next appointment in clinic. My clinic staff might not have gotten to try the Indian mangoes I brought into a morning meeting instead of the usual Krispy Kreme. I have called this country home for only about a decade, and yet, no matter where I go, I can always find something in common with Americans. I carry my stories close to my heart and I guard them—almost jealously—because I know I am e