• 1994: Fifth grade; I am charged with editing the school newspaper. There is an Intel 386 PC at home that is about to be upgraded to a 486 and do something more than run Lands of Lore.
• 1996: Seventh grade; I typeset a book of poems¹. The school newspaper becomes the school magazine — in layout only; the publishing schedule remains haphazard — as I upgrade from Word 6.0 to QuarkXPress
• 2000: High school starts again after a freshman year interrupted by NATO bombing. I make the town library’s official website. It is a php hack job laid out in tables instead of the newfangled and to me unknown CSS; it still wins an award.
• 2002-2008: Med school; I typeset a book here and there and occasionally help out with the library website.
• 2009: Teaching assistant, Institute for histology and embryology, Belgrade School of Medicine.
• 2010: Resident, Internal medicine, JHU/Sinai, Baltimore MD.
• 2013: Chief resident, Internal medicine, as above; I understand the benefits of not being invited to a meeting.
• 2014: Clinical fellow, hematology/oncology, National Cancer Institute, Bethesda MD.
• 2016: As above, but also Chief fellow ex tempore for the joint NCI/NHLBI fellowship; my hatred of poorly-run meetings intensifies.
• 2017: Staff clinician, later to be renamed Assistant research physician, Clinical Trials Team, Lymphoid Malignancies Branch, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda MD; the 1994 me marvels at the word salad trailing the title.
• 2021: Chief Medical Officer, Cartesian Therapeutics.

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.

I’m 12 and the family is taking a summer vacation in sunny Pomorie, Bulgaria. It’s on the Black Sea. The ~400-mile drive in my father’s VW Golf (Mk2) takes close to 12 hours, border check and an interlude in Sophia included. It feels longer: it’s a 3-door hatchback and I’m sharing the back seat with my brother and a suitcase. There are enough groceries in the trunk to last us a week.

We arrive in the early morning and look for a place to stay. Airbnb is 16 years away, but there are vacancy signs posted on private residences all around town. We find one that’s half-built: gray building blocks still visible on the outside and concrete stairs with no railings, but the rooms are actually quite nice and the apartment is self-contained. The owner-slash-proprietor is financing the finishing touches by renting it out. My father approves.

The weather is nice and the beach is crowded. I have a perpetual sunburn. We visit Burgas and Nessebar. Dad almost gets scammed out of all of our German marks by a street money changer. I get a photo taken with a yellow-white python around my neck. We eat at home and take evening strolls up and down what goes for a boardwalk in Pomorie. We ocasionally catch a glimpse of live music from accross a hedge. A few people climb a hillock to watch the concert. I try it once and climb right back down: do I want to spend the evening listening to a Boney M. tribute band?

The drive back through Bulgaria feels faster, but that’s because Dad is speeding. We get caught and the policeman pencils something in on a lemon-yellow card. The next time we stop for gas Dad tries to erase it. He succeeds but the card is now a paler yellow where the marking used to be. They notice this at the border and we stay an extra few hours until they let us through. But then we’re in Serbia and close to home and soon I’ll get back to playing Civilization II and Duke Nukem 3D and Quest for Glory IV so who cares what happened and how we got out of it?

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It’s 2019 and I’m the Dad. The family is taking an early summer vacation in sunny Wailea. It’s on Maui. My wife and I take two new credit cards to get enough points to get three tickets for the four of us. A week before the trip we realize I can’t have a 35-pound toddler on me for two 5-hour flights and we buy the fourth ticket. The airline charges for food, so we stock up on snacks to bring on board; I have a Costco membership card in my wallet.

We are in a one-bedrom two-bathroom condo that is bigger than my family home in Serbia. A decorative bowl full of glass balls greets us in the hallway; a large ceramic vase is next to our bed. My wife glances at our jet-lagged toddler, then at me, and I spend the next half-hour lifting fragile items up on top of kitchen cabinets. I go to bed around midnight, which is 6am Eastern Time.

The condo sits next to a golf course and some tennis courts. I don’t play either. There are five beaches within 5 minutes’ driving distance. They are virtually empty save for one, which has a steady stream of snorklers and divers parading up and down. The Costco-chosen guidebook says it’s the best spot on Maui for snorkling lessons, but 18-month-olds can’t snorkle.

The older sibling collects seashells and runs away from waves and builds puddles for the younger one to jump on. She chats up the adults and can carry a conversation better than her dad. We all wear UPF shirts and go through five bottles of Coppertone. We visit Lahaina and Paia and Kihei. We eat at home and take evening strolls through beachside resorts. There are Luaus on every night. The one at the Marriott is there for all to see from a public walkway. It’s the one we attend one night — the pork is good. There is audience participation: children learn the hula, adults blow into a conch shell; one man proposes to his fiance while up on the stage, in front of all us people — it’s a bit corny.

We wake up at 3am and wake up the kids at 4 to drive up a mountain top to see the sunrise. It is 10°C and colder with wind chill, and the sunrise lasts for all of five minutes; the children are not impressed. The other 100 people looking at it seem quite happy. One man proposes to his fiance, on top of that inactive volcano, in front of all us people — it’s quite romantic.

We sign up for an 8-hour van ride up and down a rainforest highway. It takes 12 hours. We are sitting all the way in the back: the older one is sick but doesn’t vomit, the younger one doesn’t say anything but vomits twice. It’s mostly juice and water and doesn’t smell like acid at all so we wipe it up with tissues and wet wipes and don’t ask the driver to stop. The young couple in front of us asks for more air.

The last flight back is a red-eye and the younger one screams for the first hour of the last leg of the journey because i don’t let her play with the restroom faucet. The attendents are out serving drinks so we let her roll around in the back of the plane, head close to the emergency exit door which I eye nervously. They serve us apple juice which she drinks and falls asleep. The older one is excited: there is an Amazon delivery of one toy or another waiting for her back home. She is still tired enough to be sleeping when the plane catches turbulence — the last 3 hours are bumpy. I watch a movie and try to fall asleep.

Serbia’s public broadcaster, RTS (that’s PTC in cyrillic) has a good chunk of its archive spread across multiple YouTube channels, and it is magnificent (this one in particular).

Observe the 1960s-1990s televised plays and TV dramas. I still have vivid memories of watching one particular product the first time it aired, about a Serbian family keeping in touch with their ex-pat relatives in Germany via VHS tapes. Replace camcorders with smart phones and speed up the timeline to account for the internet, and it could have been shot today. Technology changes, people don’t.

My favorite childhood TV show hasn’t aged well at all; then again has anything from the ‘90s? If you consider most of it was made during a civil war and in a time of hyperinflation it is actually quite good. What was 90210’s excuse? Better kids’ shows have been made in Serbia both before and after.

Best for last: the celebration of hard core nerddom that is Serbia’s longest-running quiz show, important enough to have its own channel. It starts with anagrams and math problems, makes a detour to Mastermind, then finishes off with three different ways to test for trivia. Jokes about the autism spectrum would be writing themselves if this were an American show, but it’s not, and (before I left, at least) Serbian viewers still had some admiration for the participants. It is all very serious and competitive, and has been on the air every weekday for the last 24 years. (A political side-note: this does not mean Serbia is free from anti-intellectualism, quite the opposite in fact. Some combination of militant anti-intellectuals, gas-lighters, and proponents of economic/financial scientism has been in positions of power since the early 90s. There are no lessons here, just observations).

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.