NOTE TO READERS: This story is Part 1 of a two-part series.

Bijender Kumar, the son of a farmer in India's northern state of Haryana, came to the U.S. on an H-1B visa in 2007 after graduating from medical school in India.

He landed a residency in Toledo, Ohio, and then earned a master's in business administration in medical business from Kelley School of Business at Indiana University-Purdue University Indianapolis in 2016.

Now, Kumar is the medical director at Hancock Regional Hospital in Greenfield, Indiana.

"It's a matter of pleasure to look back and see as to how a person who came from a modest background was able to make it to this level," he told VOA. "The fact that a person who came from what I came from can go to Kelley and sit in class with distinguished physicians is amazing."

India exports more foreign medical graduates than any other developing nation, according to the World Health Organization (WHO).

In 2016, of more than 210,000 actively licensed foreign medical graduates (FMGs) or international medical graduates (IMGs) in the U.S., nearly 50,000, or 23%, graduated from schools in India. The next-largest group of international doctors — 35,971, or 17% — are from the Caribbean, according to 2016 research by the Federation of State Medical Boards.

An IMG is a U.S. citizen or green card holder who obtained their degree outside the U.S., while an FMG describes a foreigner who completes a degree in their country of origin.

But the number of doctors who graduated in India and sought a "certificate of good standing" — required in India for working abroad — declined from 2,984 in 2015 to 1,497 in 2017, according to India's Ministry of Health and Family Welfare data cited in news reports.

Jaivir Singh Rathore, who worked as a resident in adult neurology from 2013 to 2017 at the University of Illinois at Chicago, said most foreign medical graduates struggle to get their foot in the door of the U.S. medical field. He now serves as director of the epilepsy division at the Watson Clinic in Lakeland, Florida, after working as a medical fellow at the Cleveland Clinic in Ohio and the Johns Hopkins Hospital in Baltimore.

Rathore said he came to the U.S. on a J-1 student exchange visa in 2010 and eventually received a green card that afforded him more stability. He later became a U.S. citizen through family-based immigration.

Immigration experts have indicated it could become more difficult for foreign nationals to get H-1B visas or find other immigration pathways to work in the U.S.

"Tougher green card control will force doctors to explore other options (to work in the U.S.)," said Ranvir Singh Rathore, a doctor of internal medicine in Toledo, Ohio, and Jaivir Rathore's brother.

"It's a big hassle to live and practice on H-1B or J-1 visa because of the uncertainties that loom," Jaivir Rathore said.

Visa hurdles

A foreign worker with an H-1B visa can stay in the United States for a maximum of six years; with a J-1 visa, up to five years.

"Despite the fact that there is significant physician shortage — especially regarding specialists in many parts of America — it doesn't seem like the [Trump] administration is making any significant changes to help with these immigration issues for physicians of foreign origin," Jaivir Rathore said.

The Association of American Medical Colleges (AAMC) wrote in April 2019, "The United States will see a shortage of up to nearly 122,000 physicians by 2032 as demand for physicians continues to grow faster than supply."

Exploiting doctors

"Many physicians from India and other foreign countries … consider and explore options in other countries like Canada or Australia," Jaivir Rathore said.

Some U.S. licensed physicians return to India because they are highly valued for having education, training and experience in the U.S., especially in the private health care sector, said Anupam B. Jena, an Indian American and associate professor of health care policy at Harvard Medical School.

"Some physicians that I know, including myself, think about it sometimes … to probably do part-time consultancy in India's leading private sector hospitals and with charity organizations," Jaivir Rathore said.

"As telemedicine is becoming vogue, the idea of making American dollars while living in India is becoming a reality and many Indian doctors, especially in the field of diagnostic radiology, are already doing that," he said.