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Physicians and Immigration FAQ
Source: Carl Shusterman served as a trial attorney for the U.S. Immigration and Naturalization Service (INS) and is principal of The Law Offices of Carl Shusterman, a legal firm specializing in immigration. He can be reached at email@example.com.
The Patient Protection and Affordable Care Act, a.k.a. “health reform,” will do many things to alter health care delivery in the U.S. One thing it won’t do, however, is significantly increase the supply of physicians. The new law calls for training a few hundred additional doctors each year — not nearly enough to ease projected physician shortages. As a result, foreign-born, internationally trained physicians will continue to be a vital resource for physician recruiters.
Because foreign-born international medical graduates (IMGs) must obtain work visas to practice in the U.S., it’s important for recruiters to stay current on U.S. immigration laws and procedures. Following are answers to questions recruiters frequently ask concerning U.S. immigration laws as they pertain to foreign-born IMGs.
What is an IMG?
Any person, U.S. citizen, or otherwise, who attended a non-U.S. or a non-Canadian medical school. Visa requirements only apply to non-U.S. citizens.
How many IMGs are there?
Over 200,000 — roughly one-quarter of physicians in active patient care — are IMGs. In some specialties they even represent over 20% of all active physicians.
Approximately 7,000 of the 25,000 residents who complete U.S. medical residency training each year are IMGs.
What must IMGs do to practice in the U.S.?
A system is in place to ensure that IMGs have the same skill sets as U.S. or Canadian graduates. To practice in the U.S., IMGs must:
- Obtain an Educational Council of Foreign Medical Graduates (ECFMG) certificate showing equivalent knowledge to U.S./Canadian medical school graduates
- To get an ECFMG certificate they must pass USMLE I and II, as well as the ECFMG English language test. USMLE II has been split into two parts: CK (Clinical Knowledge) and CS (Clinical Skills) so that the old Clinical Skills Assessment (CSA) test is no longer given.
- In several states, physicians can take USMLE III before beginning their residency programs. Physicians who want to enter the U.S. on H-1B visas to do their residencies must take and pass USMLE I, II, and III and receive their ECFMG certification.
- After the completion of their residency programs, IMGs may apply for state medical licenses.
What is a J-1 visa?
It’s an “exchange visitor” visa for those seeking training in the U.S., sponsored by the Education Commission for Foreign Medical Graduates (ECFMG). It gives the holder up to seven years to complete graduate medical education (GME).
However, once GME is completed, the holder must return to his or her country for two years or obtain a waiver of the two-year home residency requirement.
What is a J waiver?
A J waiver exempts the physician from the requirement that he or she return to their home country after completing their residency or fellowship in the U.S.
The most common method of obtaining a waiver is for the physician to be sponsored by an “interested government agency,” either federal or state, and obtain a job in a federally designated Health Professional Shortage Area (HPSA), a Medically Underserved Area (MUA), or a Physician Shortage Area (PSA). States are limited to sponsoring 30 physicians per year for J waivers.
In a very limited number of cases, an IMG can also obtain a J waiver if leaving the country would cause his or her spouse and children with U.S. citizenship or permanent residency to suffer “exceptional hardship.”
What government agencies sponsor J waivers?
- The Veterans Administration (VA): primary care and specialists
- The Delta Regional Authority (DRA): primary care and specialists, only in certain counties within the Mississippi Delta states
- Department of Health and Human Services (HHS): primary care only
- The Appalachian Regional Commission (ARC): primary care physicians only, limited to the Appalachian states
For links to the J waiver programs of the federal government agencies listed above, see http://shusterman.com/md-jwvr.html.
What is the “Conrad 30” program?
Not only federal agencies can sponsor doctors for J waivers. The department of health in each state can participate in the Conrad 30 program, sponsored by U.S. Sen. Kent Conrad of North Dakota. The program allows each state to sponsor 30 physicians with J visas for waivers each year.
All 50 states participate in the Conrad 30 program. Each has their own criteria for which physicians they will sponsor. For links to the state programs, see http://shusterman.com/md-jwvr.html#3.
What happens if the state has filled its 30 J waivers quota?
States vary as to when the quota period begins and most low-population states do use up their annual numbers, so this is an important factor to check. If the quota is filled, no more will be available until the next quota period begins.
What happens once a J physician gets a waiver?
If a J physician is sponsored by an interested government agency, he or she must change their immigration status to H-1B temporary professional and work for the sponsoring employer for at least three years.
If the physician receives an exceptional hardship waiver, there’s no requirement that he or she either work for a specific employer or in an underserved area.
Can IMGs start residency on any other kind of visa besides the J-1?
Yes. Some IMGs enter U.S. residencies on H-1B visas, the temporary visa category for foreign-born professionals. They must pass the same requirements as J physicians, and also pass USMLE III before applying for H-1B status. H-1B status can be extended for the duration of the program, not exceeding six years. Under narrow exceptions, a physician can extend his H-1B status longer than six years. Like the J-1, an H-1B is an “employer-sponsored” visa.
Can medical facilities hire IMGs after they complete their residency programs on H-1Bs?
Yes. If a physician obtains a suitable offer of employment, he or she can transfer his or her H-1B status from one employer (residency program) to another (medical facility). The employer need not be located in an underserved area.
Is there an annual H-1B quota?
Yes. The government will issue 85,000 H-1Bs per year. Physicians who receive J waivers are exempt from the numerical H-1B cap, as well as those who work at academic institutions and government or non-profit research institutes. If an H-1B physician wishes to transfer from a “cap-exempt” university-related residency program to a “cap-subject” employer, timing is essential. “Cap-subject” H-1Bs are available starting October 1 of each year. However, “cap-subject” H-1B petitions are accepted by the INS starting April 1 of each year. Transferring from “cap-exempt” to “cap-subject” status is complex; an attorney experienced in physician-related immigration law should be consulted.
How does a physician qualify for permanent residence in the U.S.?
While there are various methods of qualifying for a green card, the most common way is for the employer to go through the PERM process. It requires employers to demonstrate to the U.S. Department of Labor that no U.S. citizen or permanent resident is qualified, willing, or able to perform the job. This requires advertising in a major daily paper in the community where the physician is employed and advertising in a major medical journal for the job (such as NEJM or JAMA). This PERM application may remain pending at the Labor Department from six months to one year. Only when the application has been approved can the employer sponsor the physician and his or her family for permanent residence before the INS.
Alternatively, a physician who commits to be employed in federally designated underserved areas for a minimum of five years can apply for permanent residence through a “National Interest Waiver.” This relieves the employer of the necessity of undergoing the PERM process. A self-employed physician can apply for a National Interest Waiver.
Physicians may also qualify for permanent residence through U.S. citizen spouses or other relatives, as investors and through the visa lottery.
For additional information regarding permanent residence, see http://shusterman.com/toc-gc.html.
Are there quotas on green cards?
Yes, however most countries do not fully use their quotas so backlogs are usually not a concern. As of summer 2011, only physicians born in India or Mainland China are subject to lengthy quota restrictions.
Though these are some basic immigration concepts, each case has its own nuances and it’s important to review the immigration status of IMGs with an experienced legal professional to ensure the candidate has a clear path to a work visa.