Residency application season has just started. Many of the applicants, a few of whom I know in person, will be foreign medical graduates, or FMGs, meaning that they are doctors who want to work in the US but are not US citizens. Most FMGs, but not all, will also be international medical graduates — IMGs — meaning that they have graduated from a non-US medical schools. Something called the Education Commision for Foreign Medical Graduates, or ECFMG, acts as their medical school when interacting with most of the sprawling US bureaucracy. These are our personae dramatis, if you will.

Disclosure: I am both an FMG and an IMG, and first began working in the US on an ECFMG-sponsored J1 visa.

America is a net importer of physicians, that much should obvious to anyone who’s ever been in an American hospital. The country depends on FMGs to keep the system running, get the less lucrative specialties, work in underserved areas, etc. Not so obvious is that most FMGs get to America by lying; ICE-approved, foreign-government sponsored lying for sure, but lying nonetheless.

Here are the lies FMGs tell when they come in: that their country has a need for doctors of such-and-such specialty, and/or that their government is sending them to the US for training in the said specialty, and/or that at the end of training they will go back to their country of origin to work in the (sub)specialty they came in to obtain. Those are the three postulates of the J1 physician exchange visa, the very name of which is also a lie as there is no exchange taking place: foreign doctors do come in, but no American doctors come out.

The postulates are incompatible with reality, and imply foreign government competence that just isn’t there in second and third-world countries¹. Because over there, no one is keeping statistics on specialist needs, and if they are there is actually a surplus, and if there isn’t they wouldn’t be able to afford the (sub)specialists once they come back, and if they could then they would be chosen by party or family lines, and you wouldn’t want them in your hospitals anyway.

So to get a J1 visa FMGs need to obtain a letter from their Ministry of Health or equivalent stating the above (the postulates, not the actual truth; I’m sure that in some of those countries people have gone to prison for saying the truth). But is there a functioning Ministry of Health? Does anyone there know that the letter they are supposed to provide about lending a medical graduate and wanting them back is a piece of kabuki theater, and not a commitment to employ that person if and when they come back? And because this letter is supposed to come in a sealed envelope directly from the Ministry to ECFMG: does anyone there speak English? So here are all those FMGs whose main reason to emigrate to America may have been to escape their kleptocratic governments, being dragged into a game of Whom do I bribe next? and Which newspaper do I threaten them with?² by the rules of the country they were hoping was less crooked than their own.

Which is fine for America, because it doesn’t care as long as it gets its steady stream of MDs one way or another. Only it should care because 1) the amount of person-hours wasted is on par with if not greater than the amount spent writing grants, and that one’s a whopper, 2) it relinquishes control over a part of its healthcare to foreign governments, and 3) it introduces an air of subterfuge and deceit at the very beginning of the FMG-USA relationship. I would like to think this is an aberration to be fixed, and not a preview of things to come in other areas of governance.

The process was probably fine 50 years ago, when both demands of the medical system and the influx of foreign doctors were but a fraction of the current monstrosity, when USMLE was taken on paper if you had to take it at all, when it wasn’t so obvious to a non-aligned physician whether they should go to the US or USSR (or Yugoslavia, for that matter) to get more training. But healthcare has changed and so has the world: it’s time do drop the pretense of an exchange, America, and be honest about what’s going on here.

Twitter brings out the worst in people. If your worst is not that bad then power to you, madam, but most of us need to spend an extraordinary amount of energy not to look like sociopaths, or should just stay away. More often than not I choose the latter.

There are good arguments for why you should be on Twitter from both doctors and civilians. On the opposite end there is a whole book dedicated to why you shouldn’t (full disclosure: I haven’t read the book, but did read two accompanying NYT Opinion pieces back before I realized NYT Opinion pieces weren’t worth my time). So clearly there are two opposing points of view, and while I’m sympathetic to the Twitter cheerleaders and their cause, my own experience makes me take pause. Here’s why:

1. No nuance

Note the “madam” reference in the opening paragraph. Here, I have space to explain what I meant: that a well-behaved user on Twitter was more likely to be a woman. An outrage-primed stranger on Twitter just glancing at the post could instead interpret it as an attempt to emasculate the well-behaved male readers. And I forget, is it still kosher to use madam to refer to women? Or is “females” the appropriate term now, never mind that it’s an adjective? At least using “kosher” is not considered cultural appropriation yet. Right?

I don’t like this lack of nuance for two reasons: because I recognize it in myself when I overreact to a tweet and have to stop myself from writing a snarky reply and because writing down short thoughts that are still coherent is much more time-consuming than writing run-on sentences like this one.

2. Ill will

Recall Justine Sacco and the delight with which a Twitter mob tracked her WiFi-less flight across the Atlantic. Twitter mobs are pure minority rule, wherein the minority has a high follower count with an incentive to mobilize them. It is vexing to see someone with 10,000+ followers retweeting — with a snarky comment, of course — a poorly worded tweet that had thus far garnered three likes and no other retweets. No matter the content of the original tweet, and often they’re deranged rantings of an anti-vaccer, doing it to a person with a hundred-fold lower followe count and a thousand-fold lower reach is unethical at best, and dare I say immoral too when the intent of the retweet is nothing more than virtue signaling.

Again, this kills my enthusiasm for Twitter in two ways: the time I spend self-censoring my Eastern European spent-a-decade-under-US-sanctions tendency towards sarcasm, and the time I spend reading, digesting, and ultimately dismissing these worthless posts.

3. Poisoned stream

But isn’t the great benefit of Twitter over mainstream media the ability to choose whom you follow? Yes, but: Twitter the company is doing its best to ruin that by showing you not only retweets, but also those tweets that people you are following liked, and a random tweet here or there that’s been getting attention (as in: a lot of replies, as in: this is probably controversial) which it thinks may cause you to engage (as in: join the conversation, as in: enter the fray). I am not making this up.

So even if you try to keep your time line completely professional and only follow other MDs who post only their high thoughts on the latest randomized trials in the area you’re interested in… Well, you can’t stop them from liking political posts, and you can’t stop Twitter from foisting its algorithm on you.

4. No country for slow thinkers

So what? Just ignore the noise. Cull your follow list to manage input, write quickly and don’t look back to speed up your output. I suspect that’s what many people who are good at Twitter do, and if you can do it too then power to you. What kills it for me is 1) the opportunity cost (as in: I’d rather spend time with my family, and 2) (and this is the main one) I. cannot. write. like. that. This was supposed to be a two-paragraph post written in the subway. Well clearly it’s not.

As I finish writing this, a scientist I’m following has retweeted the FCC chairman’s gripe about the latest Twitter redesign. An MD is retweeting pointless videos. Random biotech factoids fly by my screen, unwanted and uncared for.

A combination of heavy rain, bad infrastructure, and even worse emergency preparedness¹ resulted in Serbia and Bosnia having the worst floods in more than a century.

Dozens are dead, and tens of thousands misplaced. Government officials are having nervous breakdowns on live TV, calling the flood “a Biblical catastrophe”—since touting vast water resources as your country’s main asset isn’t a hint as to what big disaster you should prepare for. In case you’re wondering, the Netherlands’ last big flood was in 1953.

And of course a high priest³ of the Serbian Orthodox Church blamed it on Gay Pride. Because religion².

If you have a couple of minutes, please use PayPal to donate to floodrelief@gov.rs, the official account of the Serbian diplomatic mission in Brussels. If your bank allows international wire transfers, you can give directly to the Serbian Red Cross. While no one we know is affected, my grandparents had to leave their home twice over the past 50 years because of floods. The support they and their neighbors received from the Red Cross on both occasions was invaluable.