Suicide among resident physicians is a critical issue highlighted in various studies. Research indicates that depression is prevalent among resident physicians, with rates comparable to medical students, suggesting a pervasive problem across different levels of medical training. Burnout has also been linked to suicidal ideation among resident physicians, with a study reporting that 4.5 percent of American resident physicians specializing in surgery experienced suicidal ideation. Furthermore, while resident physicians may not be at an increased risk for suicide compared to practicing physicians, studies have shown high rates of depression, burnout, and suicidal ideation among residents. The mental health challenges faced by resident physicians are exacerbated by factors such as discrimination, abuse, harassment, and burnout during training. Additionally, the stigma surrounding mental health concerns and confidentiality issues have been identified as barriers to care among resident physicians, leading to the underreporting of mental health issues.

While the demanding nature of medical residency takes a toll on all trainees, foreign-born physicians appear especially vulnerable to severe mental health challenges that can lead to suicidal thoughts and behaviors. The devastating consequences of inadequate support for IMG residents were starkly illustrated by events at Lincoln Medical Center in the Bronx, NY. In 2020-2021, at least three residents died by suicide at this institution. All three were international medical graduates who had come to the United States to complete their medical training at Lincoln’s Department of Internal Medicine. This cluster of tragedies raised serious questions about the working environment at Lincoln Medical Center. Some current and former employees have described a culture of bullying, harassment, and dysfunction within the department. These allegations suggest a toxic work environment that may have exacerbated the already significant stressors faced by IMG residents. Former residents at Lincoln Medical Center have shed light on the precarious situation many IMGs face, particularly regarding their immigration status. Many reported hesitating to voice concerns or address conflicts with supervisors due to fears of jeopardizing their work permits. This reluctance to report issues stems from the unique vulnerability of IMG residents, whose ability to remain in the United States is often directly tied to their continued employment. One former resident, speaking anonymously, recounted a disturbing incident where a senior supervisor threatened dismissal—which would have resulted in immediate loss of work authorization in the U.S.

Several factors may contribute to the elevated suicide risk for IMG residents:

Power imbalance. The extreme power differential between IMG residents and their supervisors can lead to potential abuses of authority.

Immigration leverage. Work permit dependency creates an additional layer of stress and can be exploited as a tool for intimidation.

Barriers to reporting. Fear of visa-related consequences significantly discourages residents from reporting mistreatment or seeking help.

Systemic vulnerabilities. The intertwining of employment and immigration status creates a system where IMGs may feel compelled to endure abusive conditions rather than risk deportation.

Cultural adjustment. Moving to a new country brings significant stress as IMGs navigate unfamiliar social norms, health care systems, and workplace cultures. The shock of these transitions can be isolating and overwhelming.

Language barriers. Even IMGs with strong English skills may struggle with medical jargon, colloquialisms, and rapid speech in high-pressure clinical settings. Communication difficulties can damage confidence and heighten anxiety.

Discrimination and bias. Unfortunately, some IMGs face prejudice from colleagues or patients, leading to feelings of exclusion and inadequacy. Microaggressions and overt discrimination compound other stressors.

Financial pressures. Many IMGs carry significant debt from their medical education and face visa restrictions on employment. The burden of supporting themselves and often family members back home can be crushing.

Limited support networks. Being far from family and longtime friends, IMGs may lack the robust social support that can buffer against depression and suicidal ideation. Building new relationships takes time and energy, which is scarce during residency.

High-stakes visa situation. For IMGs on visas, their ability to remain in the country is contingent on successfully completing residency. This amplifies the pressure to perform and the fear of failure.

Reluctance to seek help. Cultural stigma around mental health issues or fear of jeopardizing their position may prevent IMGs from accessing needed support services.

Imposter syndrome. Some IMGs may feel they constantly need to prove themselves, leading to chronic stress and self-doubt.

To address this crisis, residency programs must recognize the unique challenges facing IMG trainees and implement targeted support measures. Unfortunately, this is not always possible. When I was dealing with possible termination from residency and profound violations of my educational and employment rights, when I could not handle the emotional distress, no one from the university or my program tried to actually understand my struggles and failed to help me. This troubling experience illuminates significant gaps in many residency programs’ support systems and highlights potential abuses within the educational structure itself. It demonstrates that even when residents are visibly struggling, facing serious career threats, and potentially experiencing rights violations, institutions may fail to intervene, offer assistance, or address underlying issues. This systemic failure not only leaves vulnerable individuals feeling abandoned during their most challenging moments but also raises serious questions about the fairness and integrity of some residency programs. The combination of professional uncertainty, potential mistreatment, and lack of mental health support creates a perfect storm that can push residents to the brink of despair.

The author is an anonymous physician.