By Dr. Jyoti Eknoor Brar, WCI Columnist
I was 25 years old when I immigrated to the U.S. right out of my parent's house in India. I did not know anything about the US economic or social culture. All my impressions were from movies and TV, like my favorites Friends and Sex and the City (where older episodes were being played on Indian TV). I was scared but excited.
India has a very different economic and social culture where women who are in their mid-20s but still have a teenager mindset aren't expected to be financially independent. That's especially true for newly minted doctors from middle-class service families like myself who are expected to “just study” as their full-time job. I had never had to pay for anything other than the gas in my car (it was actually my father’s car, a Maruti Esteem that is similar to a Toyota Corolla), and my meager resident salary in Indian rupees (INR) was my pocket money.
That significantly changed as I got ready to move to the US. The financial investment of about $18,000 over a span of one to two years (for my USMLE preparation and exams, my travel and boarding within the US, my international travel, my US residency applications, and the rooming and food in the first month of residency) was borne by my parents as a gift (not a loan—again more common in Indian culture). As my parents were about to retire as government-employed senior physicians, their combined monthly household income was 100,000 INR ($1,333) and they tapped into their retirement (not pension) to settle their three adult children.
For further context, a fresh graduate immigrating from India who is applying for US residencies in 2022 is spending $8,000-$9,000—about half of my upper-middle-class parents' average household income at the peak of their federal government careers—on externship/board exam preparation fees and residency application fees. That doesn't include international/domestic travel and boarding/meals. That graduate will be taking a loan in India for this. Anyone who pursues an MPH or other advanced degree in the US prior to residency adds another $70,000 to their investment.
A medical school graduate from India who spent a year and a half in Canada prior to obtaining a medical residency in the US told me it took an investment of $15,000-$25,000 a number of years ago. Here's how it broke down:
- External rotation (externship): $1,500
- USMLE 1/2/3: ~$1100 * 3 = $3,300
- Boarding/food: $1,800-$2,000 per month while living in the US
- Travel from India roundtrip: $700-$1,000
- Travel within the US: ~ $400 per flight
- UWORLD exam preparation: $300-$900
- Residency applications: $1,330
For whatever reasons that a medical school graduate from non-US countries decides to do a residency in America, it helps to provide a roadmap of the new “financial residency” that starts within that first week, the first month, and the first year of landing in the US.
The following is a survive/thrive guide when an International Medical Graduate (IMG) has been lucky enough to procure a residency spot and start their career. Keep in mind: these are the steps I took and what most IMG who have no base or contacts in the US will have to do.
What to Do in the First Week in America
The first week in the US as a new employee immigrating from overseas is like being a newborn baby.
#1 Get a Social Security Number
You'll need a Social Security number before anything else. Google your nearest Social Security office and take an Uber or request a ride there with the required documents.
#2 Get a Bank Account
You will usually need your employment contract and a rental lease in addition to a passport and other required documents to open a bank account. This will get you a debit card for going cashless since it could be unsafe to carry more than $20 in your pocket when returning late at night from your residency rotation. You will likely not be issued a credit card right away since you have zero credit history—a way for US businesses to determine if you can be trusted to borrow from them.
Start working on building your credit history in your first week by getting a credit card from the local grocery store, Macy’s, Express, or whoever will give you one. Use that credit card to pay for your expenses and then make on-time paid-in-full payments each month to help you build your credit score.
#3 Rent an Apartment
This can be done online prior to your arrival in the US, via video touring (in my experience, people here will usually deliver what they have promised). Don't let the rent be more than 20%-30% of your take-home monthly pay. Be ready with cash to pay for two months' rent in advance and/or a hefty security deposit, and choose an apartment in the usual resident-friendly complexes near your place of work. Some people will choose to share an apartment for the first few months or a year—it’s a personal decision. The rental leases are usually six months to one year long, and although you can leave a lease earlier than that via subletting, you definitely don't want to break a rental contract.
#4 Find Transportation
You might need to take an Uber everywhere, which would be expensive, or schedule errands according to your benefactor’s schedule (if you happen to have a benefactor). You’ll need to buy groceries and some basic furniture and utensils (or request some from a nearby church or place of worship). How to find a ride? Use your network of fellow IMG residents or US-born residents who already have a car and who have the same rotation as you.
#5 Buy a Phone
I don’t remember this being an issue for me at all. I got my first Apple phone in 2008 here in the US on a monthly payment plan.
For peace of mind, I suggest foregoing the mental math of converting everything from US dollars to INR. I remember my first lunch of a single piece of pizza for $7 from the nearest walkable grocery store. It freaked me out how expensive the US was and how I was burning through my parent’s money and the $1,300 stash they’d given me to live on until I received my monthly resident salary of about $3,500. I was happy that my future husband would be visiting me soon (via a Greyhound bus ride from Philadelphia to Buffalo) to help me “settle in.”
My future husband didn’t even have a residency job or any kind of US salary (and was on a similar parental grant like me). But we shared our first lunch on a newspaper spread out on the carpet of my newly rented apartment.
Many IMGs have similar experiences when they first land in the US to start their new job. Most feel extremely blessed to have a job and hope that they can live their purpose and pay off their family's investment in them.
What to Do in the First Month
Now that you're beginning to get settled into your new life, here are some next steps.
#1 Learn to Drive
I went to driving school to learn how to drive in the US and then got a learner's permit.
#2 Buy a Car
Buying a car was something that I would do differently. I bought a new Toyota Camry at a high-interest rate and paid more than $1,000 per month in car insurance due to lack of credit and driving history. Many car dealers will require a cosigner on your loan—someone who can guarantee that they’ll pay it off if you can't. Getting a cosigner in a new land where the only people you know are new immigrants like yourself is a difficult and undesirable task. It was a favor that I didn’t want to ask of anybody at the time.
How do you find a cosigner? You can mine your parent’s network for an established responsible adult who has a good credit score. I bought a new car in 2007 because my Indian mindset was one of suspicion for used vehicles. In India, you rarely receive what you pay for if it is second-hand. But preowned/certified vehicles in the US are very reliable and are available at a much cheaper purchase price.
Out of all these tasks, it's most important to arrange to buy a car, because it’s hard to find an Uber at 5 a.m. when you need to be at work at 5:30 and you’re still converting the car fare in US dollars to Indian rupees.
#3 Set Up Your Utilities and Decide on Your Benefits
You will NOT get time off from your residency schedule to attend to matters of life, like setting up a Social Security number, getting a driver's license, setting up your utility bills and bank accounts, or arranging to be available for your internet installation appointment.
Even if you’re a 25-year-old woman who had not left her parent’s home before starting her residency, you don’t want to bring your parent to “settle” you in. That will cost even more money to your parent, who will be as immobile and unknowing of how life works in America as you. Add on top of that a new healthcare system, a new country’s culture, and, of course, the new residency.
How to set up your accounts: once you have internet and an apartment, this is easy (you can set up services using your laptop).
During orientation, graduate medical education (GME) had me choose my benefits—life insurance, disability insurance, medical insurance, etc. If you’re like I was when I first came here, you may be clueless about U.S.-based benefits, as you might’ve only heard about Indian-based provident funds, LIC, and LTC/Travel benefits from your parents. For more information, here is the American Medical Association's IMG toolkit.
What to Do in the First Year to Thrive
Now that the first week and first month are behind you and you’ve settled in, how can you start securing your financial future? Remember, your monthly US resident salary could be less than that of an average middle-class American ($40,000-$120,000 per year) but more than a surgeon in private practice in India who is 10 years out of their surgery residency.
The following information pertains to those FMGs on a work visa, their dependents (for immigration purposes), and those who don't plan to leave the US before the age of 59.5. Investing in tax-advantaged accounts for non-US citizens is a useful guide if one is undecided about staying in the US long-term.
#1 Understanding Your Salary and Benefits in Your Employment Agreement
This is a sample contract from my residency program. I don’t recall reading or understanding it except for the H1B visa clause. All other benefits are insurance premiums or, as I like to think of it, the rent you pay to wear an invisible protective coat against malpractice lawsuits, disability (interestingly, it is pretty useless for visa holders), health expenditures, etc.
An HSA has a way to build wealth, but the FSA does not and is use-it-or-lose-it pre-tax money set aside for known (usually) health expenditures—it may make more sense for those IMGs arriving with their dependents to look into this.
If you are comparing salaries when choosing your residency program, remember that the salary schedule and the dollar value of this invisible protective umbrella of benefits is your total compensation. My main criteria for choosing my program was that it would offer me a pre-match (sure-shot offer of employment), that it had all fellowships available, and that, at that time, was sponsoring H-1B visas (some only offer J-1 visas, while some offer green card sponsorships during residency).
#2 Roth IRA and Spousal Roth IRAs
Invest in a Roth IRA or a spousal IRA only if you plan to stay or retire in the US.
#3 Look Into Getting a Money Match Via Your Residency's 401(k) or 403(b)
If your residency offers a money match, it's a part of your salary and should not be left on the table for the employer. It is a way for the employer to retain you. For example, if the residency says it'll match you dollar for dollar after year 1, it's really wanting you to stay into year 2 to claim your money match. Another pointer here is not to frontload your 401(k)/403(b) in the first few months. More information on this here.
#4 Tax Breaks for Medical Residents
Some of these tax breaks for residents do NOT apply to non-US residents. I still paid H&R Block in those days to do my taxes while my engineer sister who moved to the US in 2015 has always done hers through Turbo Tax by herself. Don’t worry, though. In their income bracket, medical residents oftentimes will get a tax refund.
#5 Repaying Your Family’s Investment
If you’re like many immigrants, you’re probably sending a sizeable chunk of money back home to help family and friends. This is a personal decision. The money you send back now is not growing (via investing) for a future life event of that family member you’re trying to help now.
#6 Children’s Funds
If you have children, you can open a 529 college savings account that can only be used for qualified educational expenses or a UTMA (owned by the parent until the child is an adult and usable on anything) for them from the money gifted to them by your family and friends. This was also a somewhat helpful survival guide for those moving from India to the US.
#7 Non-Qualified IRA
If you magically still have some cash left over, you can invest in the US financial markets by opening a taxable brokerage account at Vanguard. Just try not to let cash sit in a bank account earning <1% interest.
#8 Emergency Fund
Try to keep up to six months of expense in your bank account before investing elsewhere.
If you're moving to the US from India, this was also a somewhat helpful survival guide.
As for me, I survived by trial and error (like all humans do). My financial journey was limited to the tactics I’ve enumerated in the first week and first month up until a year ago. I wish I’d understood the action items in the first-year section so that I could’ve started building wealth from year one instead of feeling like I had to trade my time for money this whole time. But then again, “better late than never.”
A major decision that held me back was whether I wanted to stay in the US or return to India and how different the wealth-building paths would be. I hope this column will help all those who are thinking about migrating to the US or those who have been here for many years. I hope it will also help the medical residency stakeholders understand what a newborn-like foreign medical graduate is undergoing on day one of their new job. And I hope you remember that a little kindness goes a long way in impacting these promising individuals.
If you're an IMG, did you follow a similar path to find your financial footing in a new country? What are the best decisions you made? Is there anything you regret? Comment below!
What a fantastic article posting the realities of IMGs by Dr Brar.
We have thousands of fortunate students who grow up in America and working their way into medical school. But, when comparing their situation and their story to the challenges, struggles, uphill climb that an IMG goes thru from Africa, LATAM, E-Europe or almost all of Asia, there is absolutely no comparison.
It is the fortunate few that are able to qualify from a monetary angle, but a ton of them are able to qualify from an educational angle (MCAT / Step 1 etc). AND, yet it is only the fortunate few that are able to have family support as they try tomake it across the borders.
This article is extremely helpful and hopefully will be quoted and requoted many times for the preparatory materials and links that you have provided in a single article that could make their transition easier AND simpler just simply based on the hyperlinked content
Finally, these same students live thru the same student medical loans that any other American student goes thru which levels the field for the most part. It is not important at that stage since these loans are a subset of the potential earnings coming right after Residency, but yet it is a shockingly large amount esp when you consider the potential annual earnings of the parents back at home.
Having lived thru the stories of many coming to America over the last 35 years of my life in America, I have a lot of pride in those IMGs coming from across the pond/borders and would suggest/recommend the locals (westernized world students) to have your kindest consideration to your future peers (based on their merits) and accept them in the best possible way. Teaching them the way of life here in America in many different angles/ways is the best way one can make a life-long-partnership with these IMGs who have lived their entire 20-25 years outside of the US, and yet have capacity to fill the gaps in the US Medical Society.
A very similar inflow of IT Professionals has been happening in the last 10-15 years, with most in the last 5 years to perform the Digital Transformation to the Metaverse environment that is about to be unveiled in the coming 1-5 years. And, this whole IT environment of USA has accepted these professional with both arms, in a manner similar to the Medical Professionals.
Hope I have written what would be an opinion with facts that I have seen/experienced and not mis-represented anything here in the world of equality of humans from around the world.
Ken
Thank you! Yes,my whole intent with this article is to make the transition easier for those that come to this Land of Opportunity.
Loved learning about your story and reading your tips, thank you for sharing!
Wonderful! I am not even in the field, but what a great way to help others considering residency in USA who don’t presently live in USA. Maybe there is a way for hospitals to send this to admitted new residents for other countries?
Yes! I hope any Residency stakeholders reading this will share this guide. As the AMA toolkit cited in my article confirms,there aren’t any guides for FMG’s financial roadmap. Financial health reduces burnout in my opinion.
As an Aspiring IMG ,clueless of the financial path to be taken by a foreign medical graduate this article is extremely helpful. Thank you so much for sharing your experience and insightful thoughts.
I wish someone told me a quarter century ago, when I came from a disintegrating post-Communist country to the US: the sooner you move from “labor” ( ie wages for your efforts and time) to “capital” ( your money working for you no matter whether you’re working or not), the better your financial health would be. Money from your labor come only when you work and are heavily taxed. Money from capital come no matter what and are taxed lightly.
You don’t absolutely need a business or real estate to do that, you can stick to 401k, 403b’s, IRA’s and taxable brokerages etc. and still win the game
Thank you for sharing your thoughts. Please add any other helpful tips to build wealth for an FMG ,whether they’re in their first week or tenth year living in the US.I am sure I missed out on some tips and that’s why a collective effort from all FMG’s may enrich this post as a future reference for those who come after us to the US.
I would argue that money doesn’t come from capital “no matter what.” Capital is rewarded when it is put at risk. Little risk, little reward. I agree with the rest of your points.
So true! Risk…Returns. When I got over my fear of losing my money (by thinking “I’ll make more if I lose this because I’m a doctor”),I started to invest.Before that everything lay in the bank losing capital to inflation.
We all, FMG’s included, need to make a time investment in our financial education. This education doesn’t have to cost you a ton of money. WCI is a great free resource with more than enough info to put anyone who wants to become financially independent on a right track.
One thing going for FMG’s is that, by and large, we don’t have a high educational debt. On the downside, many of us are in lower-paying specialties ( there are few exceptions, of course)
So the sooner we start actively educating ourselves and investing, the sooner we can become financially independent
And yes, WCI is right as always, you’ve got to become comfortable with a degree of risk ( for some it’s high, for others it is low)- market rewards you only for risk
At the same time, looking back now, I would say we need to stop once in a while and smell the roses. We need to learn how to enjoy our present life while preparing for the (financially independent) future as alas, the future is not guaranteed as we all know too well
So very true. I remember my residency PD had a noon conference on 403b and it just went over my head. 6 years into being an attending, I finally invested in financial education i.e. WCI and feel more prepared. Wish I had known sooner!
That’s great to know that your residency Pd dedicated some time to financial education for his residents. Kudos to him/her and to you for investing in your future.
Bravo, Dr. Brar. Your post is an excellent primer for any medical grad coming from a foreign country. (I have a few relatives who were in that position and they certainly could have benefited from your insight and resourcefulness in dealing with the monumental transition).
I look forward to more well-writtwn columns from you on WCI.
Dr. Brar, thank you for publishing this piece! As an American, I had NO idea what it takes to move from India to the US and start from scratch—at the same time as starting a residency, no less! I really enjoyed learning about your journey. I am truly impressed by the courage and fortitude of my IMG colleagues- I had no idea the level of stress that must have been going on for you— and yet, you carried on and excelled like water off a duck’s back. I hope you and your family continue to thrive! Let us know with a follow up post!
Amazing article, doctor. I am an IMG from Vietnam and I know how difficult it was when it came to finance for non-US born doctor. I also had my post in finance for IMGs but I wrote it in Vietnamese. I am PGY1 in Family Medicine. As a Vietnamese doctor, I gotta pay more than 26k usd for just USMLE prep and tests ( NOT including food, sheltering, traveling, transportation, car/ health insurance )
Wow!26k just for USMLE prep and tests? Can you quote some of the websites here from where you got those numbers? Eg. Is the USMLE fees x times more for Vietnam than for India? Or do Vietnamese medical students take much more expensive preparation materials than Uworld? Almost no one I know in India takes the official Kaplan prep which costs thousands of dollars.
Lmao, that was what I did. In Vietnam, there are very few MD who had done USMLE and we don’t actually have a good association to guilde new MDs on this pathway. The only thing I know was kaplan prep course. That’s why the number went up. Another thing was about ERAS application. As I mentioned, no one guilde us on how to choose programs, how to do research about programs correctly, so I ended up with applying 300 programs