Coming to (and staying in) America

For Latha Achanta, M.D., it was a tense time fueled by the anxiety that one mistake could threaten her future as a physician. Fresh off a master’s degree in public health from the University of Texas, Achanta was in the United States on an F-1 student visa at the time. A native of India, she was applying for her H-1B visa to train in a United States hospital in internal medicine.

“Initially, the process was anxiety-producing,” says the 29-year-old Achanta, who recently completed her third year of residency at Abington Memorial Hospital in Pennsylvania.

Relocating to the United States

The United States allows International Medical Graduates (IMGs), also known as Foreign Medical Graduates (FMGs), the opportunity to train in American medical institutions, as long as they meet minimum entrance requirements. Due to the undersupply of graduates from American medical schools, especially ones willing to go into family practice or internal medicine, this arrangement has historically benefited both the foreign physician and the hospitals.

Types of physician visas

Two types of visas are offered to IMGs: the J-1 and the H-1B.

Most IMGs prefer the H-1B visa. The reason is simple: Those arriving on J-1 visas have up to seven years to complete their training. But after that time period, they must return to their home countries for at least two years or else file for what is known as a J-1 waiver.

The J-1 waiver has a major restriction that makes it less than desirable for many foreign physicians. To qualify, the recipient must serve for at least three years in a U.S. Medically Underserved Area (MUA), a Health Professional Shortage Area (HPSA), or a Medically Underserved Population (MUP). This alone might not be a significant barrier, but openings might not be available in their practice specialties or preferred geographic areas.

The H-1B has no such return provision and can be renewed, but it is considerably harder to obtain, says Robert Lubin, an immigration attorney for more than 25 years and founder of Robert Lubin & Associates in Herndon, Va. “For one thing, the H-1B requires that the IMG first pass the United States Medical Licensing Exam,” Lubin points out.

Muhammad Balouch, M.D., a 32-year-old internal medicine resident at Mount Sinai School of Medicine’s Veterans Affairs Medical Center in the Bronx, N.Y., chose the H-1B route. “You avoid having to go back home or getting an exemption,” says Balouch. “The H-1B is the quicker route to a green card.”

The International Medical Graduate journey

In all cases, the process begins with an application to the Educational Commission for Foreign Medical Graduates (ECFMG), a United States organization that oversees the process of certifying the credentials of IMGs for entry into U.S. residency training. All IMGs, regardless of citizenship, must be ECFMG Certified in order to begin U.S. residency training.

IMGs, like graduates of U.S. programs, use the Electronic Residency Application Service (ERAS) to submit application materials to U.S. training programs. Competition for U.S. residency slots is highly competitive and a substantial hurdle for many IMGs.

Most residency contracts are offered through the National Residency Matching Program (NRMP), a clearinghouse for accredited graduate medical education (GME) positions. A small percent of accredited slots are offered outside the NRMP. In addition to the contract, the foreign national physician must also apply and secure a U.S. visa authorizing clinical training. Generally, the visa application process can begin only after an official GME contract has been offered.

The J-1 and H-1B visas are by far the most common options for residency training. ECFMG serves as the visa sponsor for all J-1 physicians enrolled in GME. J-1 visa sponsorship requires direct coordination between ECFMG, the foreign national physician, and the teaching hospital offering the residency contract.
A good reference for all IMGs or foreign nationals graduating from U.S. medical schools is The International Medical Graduate’s Guide to US Medicine and Residency Training ($49.95), published by the American College of Physicians.

The residency match program through the NRMP is a substantial hurdle for many IMGs. The applicants indicate their areas of interest and, typically after the U.S. graduates are placed, the hospitals again review the applicants.

“Everyone is looking at the same pool of resident applicants,” reports Diane Maloney-Krichmar, Ph.D., director of medical education at Baltimore’s Sinai Hospital. “Then we submit a rank list to NRMP and the residents themselves submit a rank of their top three hospital programs. The NRMP computer program eventually matches them. In between, we invite people for interviews.” Due to the many variables involved in making selections, some 250 interviews might be needed to fill 75 positions.

“The people who want to go into internal medicine are a smaller group, because most medical students want to go into more highly specialized fields,” Maloney-Krichmar says. “That’s why we have to start with such a large pool in order to fill our needs.”

The residents pay for their own expenses for the interview, which may be a financial barrier for some and the first self-selection out of the pool. “Half of our medicine residents are IMGs,” Maloney-Krichmar points out. “They come from all over the world. The hospital couldn’t possibly afford to pay for this itself.”

The waiver process

Once the seven years are up on a J-1 visa, the physician must either return home for two full years or seek a waiver.

Waivers may be granted for several reasons. One is a hardship waiver available to those for whom going back to their home country would constitute extreme hardship to a spouse or child who is a U.S. citizen or permanent resident. Another option is the asylum waiver, granted to those whose return home would result in persecution.

10 relocation tips from the experts

To make the J-1 or H-1B application and J-1 waiver process easier and more efficient, immigration attorneys, health administrators and physicians who have been through the visa and waiver process recommend the following:

1. Hire an attorney. If the employer does not provide free application assistance, hiring an attorney is considered money well spent, especially for the H-1B process.

2. Stay positive. The visa application process is bound to hit a snag or two given the bureaucracies involved. Stay focused on the end goal.

3. Start early. Whether applying for a visa or researching waiver opportunities, starting early is always a good idea.

4. Make sure you ask questions. Stay in close contact with the attorney and ask for a thorough explanation of anything in the process you do not understand.

5. Pay attention to the contract. Physicians are well advised to hire an attorney to review the employment contract.

6. Check references. If you are looking for a waiver position and use a reputable placement firm, ask for—and check—references.

7. Do your research. Prior to any waiver position interview, thoroughly research the opportunity, practice selling your skills, and arrive prepared with a list of questions. Make sure the practice is in line with your personal and professional goals.

8. Nail the interview. When interviewing for your waiver position, dress appropriately, arrive on time and, assuming you are comfortable with the opportunity, positively assert to the interviewers that you would like to work there.

9. Discuss contract specifics. Research salary comparables in the area before you arrive. Find out about benefits and lifestyle issues.

10. Say thank you. Even in the age of e-mail and text messaging, nothing beats a personal thank-you note on a classic note card.

The most commonly used waiver, however, is the Interested Government Agency (IGA) waiver. IGA sponsors for physicians, such as the Appalachian Regional Commission, Delta Regional Authority, U.S. Department of Health and Human Services and U.S. Department of Veterans Affairs, typically require that the physician seeking the waiver work at a HPSA, MUA or MUP.

There is another way to secure a J-1 waiver. Each state is allowed to grant up to 30 J-1 waivers to underserved areas. Known as the Conrad 30 program, each state sets its own requirements, making it imperative that interested physicians thoroughly research the programs well in advance. Some states allow waivers for physician specialists while others do not, and they can have very different application processes. States may also have different start dates, which will impact the waiver-seeker’s chances for success.

Nidhi Kaul, M.D., was initially admitted on a J-1 visa to do medical research as an exchange scholar following her graduation from medical school in India. Kaul recently completed her family medicine residency at Wyckoff Heights Medical Center in Brooklyn, N.Y.

“I’ll do my J-1 waiver exemption in a Connecticut medical facility for three years,” says the 32-year-old Kaul. “Then I’ll go back into a fellowship in research and will go for an H-1B at that time. I know I will have to hire an attorney for that, in fact. I have no idea of that process.”

Achanta’s journey from F-1 to H-1B was different from Kaul’s, but follows a familiar pattern. “As I was nearing the end of my residency, I looked for a place that would continue my H-1B and would be willing to sponsor my green card. I was fortunate to secure a position at the University of Arkansas for Medical Sciences,” she says.

For the IMG, the visa application process can be daunting. “It was a hassle,” reports Kaul, who spent the first eight years of her life in the United States, but moved back to India with her family to care for aging relatives. “In my case, I had to write the same letter five or six times to prove why I wanted to move from research to clinical and how the research I was doing would actually help me in my clinical practice. The ECFMG is really helpful in going through the process. Only if you’re coming from research to a clinical do you have to be really careful. You have to show that you’re doing something related to medicine, to something you’re going to practice ahead.”

Balouch, who is here on a H-1B, echoes the concerns expressed by many IMGs. “At the time you apply for a H-1B, it’s a tough time. You worry that it may not come in time, or that there may be some problems that could delay your residency. But in the end, in my case there were only minor issues, and it went well.”

Smoothing out the relocation process

Speak with a dozen different J-1 or H-1B recipients, and you will hear a plethora of ideas for making the application process easier. The most common suggestion? If you are applying for a H-1B—and if you are given the option, they all do recommend choosing the H-1B—get a lawyer.

“In some cases, the applicant hears an attorney say, ‘I have a special in with so-and-so, and by hiring me you’ll get it faster,’” says attorney Robert Lubin. “That’s generally not true. It’s not a question of knowing somebody, but of getting it right the first time. And that’s why you also want to hire somebody who does a lot of these.

“From the standpoint of the hospital or clinic, every week without a doctor is going to be costly both in terms of patient health and the economics of the practice. So if you blow three weeks, that’s real money—a lot more money than the attorney’s fee could possibly cost.”

Due to its complexity, most experts recommend using an immigration attorney to process the H-1B, preferably a referral from someone you trust who has used that lawyer before.

“Have the right person handle your application,” says Achanta. “The way they present you is critical. Even if it costs, it’s worth it.”
Attorney fees fall within an average range of $1,500 to $3,000 for an application.

“Once you’ve found an attorney with a lot of expertise, then you want to make sure the fee is reasonable and that you’re comfortable with the person,” adds Lubin. “He or she is someone you will have to work with for awhile.”

Stay positive

Another recommendation for IMGs is to stay positive throughout the process. There are many more opportunities today than there are doctors, so though IMGs may not get their choice, the odds are stacked in their favor.

“Even before applying, get every bit of paperwork straight, including educational documents and proofs of degrees,” Balouch suggests. “And be sure to start the process early.”

Maloney-Krichmar offers advice from the institutional side of the coin. “Our internal medicine program has a survival guide they give the IMGs. It tells them where to shop, how to get a Social Security card, cash a check, and get a bank account. They come in new to the country and certainly to the city. They may not have friends. They’re put on the floor right away working up to 80 hours a week. Support services for the IMGs are critical,” she advises.

All across the country, institutions find themselves challenged by the demographic shift toward diversity. Again, Maloney-Krichmar provides perspective: “We believe strongly that a diverse resident and nursing population strengthens our cultural competence and our patient-centered care since our patients are increasingly diverse. We have put more focus on cultural awareness than we did in the past. So, for example, you have to educate someone schooled in India on how to take care of Russian Orthodox Jewish patients. It’s a strength but also a challenge. It’s pretty interesting.”

Attorney Robert Lubin agrees with Maloney-Krichmar’s perceptions on diversity. “Maybe we need to get used to something, but once we do, America is the most open country to other people. In the end, the physicians who come here on J-1s and H-1Bs help us as much as we help them.”