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Hi All:

Foreign Medical Graduates who have passed Step I and II will be bombarded with many issues before they could be successfully matched in residency programs. One of the issues is the type of US visa and prospective “destination” where one type of visa might lead to. I find the following article, which was written by an immigration attorney worked with the US IMS previously, depicts a very clear “route”. It is not only a good reference for new comers, but also a brief guide for those currently in the US participating the training programs to consider their next move after, if they would choose to stay.

Happy reading.


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Coping with U.S. immigration laws

International medical graduates (IMGs) should know their visa options if they want to work in the United States. And so should their employers

BY CARL SHUSTERMAN*

According to the American Medical Association (AMA), over 20 percent of all active physicians today are international medical graduates (IMGs). Some specialties are comprised of over 30 percent IMGs. While an increasing number of IMGs are U.S. citizens, the majority are still foreign national physicians who must contend with U.S. immigration laws if they wish to live and practice here.

U.S. immigration law can be complex and each physician’s case may be different. However, there are general terms and concepts IMGs and their employers should be familiar with if they want to negotiate their way through the maze of existing rules and regulations.

Basic requirements. IMGs first need the following in order to practice medicine in the United States: 1) A degree from a foreign medical school. 2) An Educational Commission on Foreign Medical Graduates (ECFMG) certificate showing the physician has knowledge equivalent to that gained at a U.S. medical school. To obtain an ECFMG certificate, IMGs must pass the U.S. Medical Licensing Exam (USMLE) Parts 1 & 2, pass an English exam, and pass the Clinical Skills Assessment (CSA) exam.

J waivers. Many IMGs come to the U.S. to train on Exchange Visitor or “J visas.” This type of visa requires the holder to return to his home country for two years before being able to practice medicine in the U.S. An exception to this rule may be obtained if a U.S. government agency will sponsor the IMG for a J waiver. Over 1,000 IMGs are sponsored for J waivers each year. In general, employers must be located in federally designated Health Professional Shortage Areas (HPSAs) or Medically Underserved Areas (MUAs) to obtain waivers for J visa holders, and the physician must practice primary care or psychiatry. However, the Veterans Administration (VA) sponsors both specialists and primary care physicians in its facilities across the U.S.

Sponsoring agencies. Several federal agencies currently sponsor IMGs for waivers. These include the Appalachian Regional Commission (ARC), the Department of Health and Human Services (HHS), and the VA. The Department of Agriculture (USDA) used to sponsor IMGs for J waivers but ceased doing so in 2002. This has greatly inhibited the efforts of rural health-care facilities to recruit IMGs on J waivers. In addition, each federal agency still sponsoring J physicians has its limitations. ARC only sponsors J physicians in some 13 Appalachian states, while HHS sponsors some 200 J physicians annually in research positions and has recently started sponsoring a few primary care physicians. The VA only sponsors physicians directly employed by one of its facilities.

The “Conrad 30.” This program, authored by Senator Kent Conrad of North Dakota, allows any state to sponsor up to 30 IMGs for J waivers each year. Almost every state participates in the program. Like the federal program, IMGs must work in HPSAs or MUAs, but not all states require that they practice primary care or psychiatry. Given the limitations of the federal sponsoring agencies, the Conrad 30 program is an increasingly attractive option for IMGs seeking J waivers.

H-1B visas. The H-1B is an employer-sponsored temporary work visa for foreign professionals, allowing IMGs to live and work in the U.S. for up to six years. Some IMGs attend U.S. residency programs on H-1Bs, with the residency program acting as the sponsoring employer. In contrast to J-1 physicians, who only need USMLE Parts I and II to work as residents, IMGs with H-1B visas must have completed all three parts of USMLE, or have completed Federation Licensing Exam (FLEX) or the National Board of Medical Examiners (NBME) exam. Before filing for an H-1B, physicians must be licensed in the state of intended employment. The employer must file a Labor Condition Application with the U.S. Department of Labor and, subsequently, an H-1B petition with the Immigration and Naturalization Service. The number of persons who may be sponsored for H-1B status is limited to 65,000 annually. In fiscal year 2004, this numerical cap was reached on February 27. There are, however, some employers and physicians who are exempt from the numerical cap.

Permanent residence (“green card”). IMGs in H-1B status may file for permanent residence or a green card if they wish to stay in the U.S. indefinitely. There are a number of ways IMGs may obtain green cards and the appropriate strategy will depend on each IMG’s particular circumstances. What is important to remember is that IMGs on H-1B visas must obtain green cards before the H-1B expires. If they do not, they may fall out of legal status and be unemployable.

O visas. The O visa is commonly referred to as the “Super Star” visa, because it is granted to physicians and other professionals who can demonstrate “extraordinary ability” in their fields. For a physician, this means multiple publications and citations demonstrating preeminence in a particular area. The threshold for demonstrating extraordinary ability is very high.

Canadian physicians. Canadian-educated physicians are not considered IMGs. They may obtain medical licenses in most U.S. states and obtain green cards based on their Canadian training and exams. However, they cannot obtain H-1B visas unless they have completed a U.S. qualifying exam, either the USMLE, NBME, or FLEX. Canadian physicians who have completed a U.S. exam can obtain H-1B visas and work in the U.S. in a matter of weeks. However, those who do not have a U.S. exam may have to wait up to two years to obtain a green card.

Best strategies. For most IMGs, the road to a green card lies through an offer of employment—in particular, employment with a medical facility in an underserved area, if the IMG needs a J waiver. Publications like Unique Opportunities, The Physician’s Resource are good places to find medical jobs, and recruiters may be able to help. However, IMGs seeking waivers may wish to identify hospitals in HPSAs and MUAs and contact them directly about employment. A free directory of all the HPSAs and MUAs is featured on my Web site, www.shusterman.com.

While immigration laws and procedures can seem mystifying, there often is a way out of the maze if you have the patience and resourcefulness to find it. As in patient diagnosis, knowing the possibilities and asking effective questions are the keys.

*Carl Shusterman served as Trial Attorney with the U.S. Immigration and Naturalization Service (1976-1982) and is principal of the Law Offices of Carl Shusterman, Los Angeles, California. He may be reached at carl.shusterman@gte.net.

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