Rules and Guidelines for Recruiting Foreign-Born Physicians
Over the last 25 years, foreign-born physicians have become an integral part of the medical workforce. Over 22 percent of active physicians in the United States are foreign-born graduates of
international medical schools.
Today, foreign-born physicians are a particularly important resource of primary care physicians. Graduates of international medical schools, the great majority of them foreign-born, now comprise over 50 percent of first-year family practice residents. Of the 24,000 or so residents who complete
training in the U.S. each year, approximately 6,000 to 7,000 are international medical graduates (IMGs).
While some community health centers do utilize foreignborn physicians in their practices in cases where they’ve faced difficulties in recruiting U.S.-born primary care doctors, it is expected that many more health centers will explore this option as a part of their overall workforce development strategies to expand health care access under the recently passed health reform law.
The following provides some of the basics that apply to immigration rules and employing foreign-born physicians.
What is an IMG?
An IMG is a foreign national physician trained in any country other than the United States or Canada. This excludes U.S. citizens who trained in non-U.S. or non-Canadian medical schools, though they also can be referred to as IMGs. Canadian nationals who are Canadian-trained also are not considered IMGs. They constitute a separate category briefly referenced in this article.
What do IMGs need to practice medicine in the U.S.?
They need a degree from a foreign medical school and an Educational Commission for Foreign Medical Graduate (ECFMG) Certificate, which shows equivalence to knowledge gained in a U.S. or Canadian medical school. To get an ECFMG certificate, IMGs must pass the U.S. Medical Licensing Exam (USMLE), Parts 1-2, and pass the ECFMG-administered English language exam. They also must complete a U.S.-based residency program.
Canadian-trained physicians, by contrast, can be licensed in most U.S. states based on their Canadian exam and training.
What type of visa do IMGs need to get into a U.S. medical residency program?
Most IMGs get into U.S. residencies by obtaining either “J-1 exchange visitor” status or “H-1B temporary worker” status, known respectively as J-1 visas and H-1B visas. IMGs need to pass all three parts of USMLE to enter U.S. residencies on an H-1B visa, while they only need parts 1 and 2 to enter on a J-1 visa. However, IMGs on J-1 visas are obligated to return to their home countries for two years after completing their training before they can perform patient care duties in the U.S.
By contrast, IMGs on H-1B visas do not have to abide by the two-year home residency requirement. J-1 visa holders also can avoid the two-year requirement by obtaining a “J waiver.”
How can IMGs obtain a J waiver?
To obtain a J waiver, an “interested government agency” (IGA) must agree to sponsor the IMG to work in a federally designated Health Professional Shortage Area (HPSA) or a Medically Underserved Area (MUA). There are thousands of these areas throughout the United States, many of which are served by Federally Qualified Health Centers. You can determine if your health center is located in one of these areas by visiting: http://bhpr.hrsa.gov/shortage.
In addition to IGA waivers, a limited number of waivers are granted to physicians whose spouse and children, if they are U.S. citizens or permanent residents, would suffer “exceptional hardship” if they had to return to the physician’s home country. Moreover, a few physicians are granted waivers on the basis of persecution they might encounter if they had to return home.
Because of their mission of providing care to the underserved and because they receive federal funding, physicians employed by Federally Qualified Health Centers
are more likely to be granted J waivers than are physicians employed by traditional private practices.
Who sponsors J Waivers?
Federal sponsoring agencies include the Department of Health and Human Services (HHS), the Veterans Administration (VA), the Appalachian Regional Commission (ARC), and the Delta Regional Authority (DRA.) These agencies sponsor mostly primary care physicians for waivers.
In addition, the Conrad 30 program allows employers in each state 30 J waivers per year. All 50 states participate in the program. Most of these programs will sponsor both primary care and specialist physicians for J waivers.
What happens once the J-1 physician gets a waiver?
They convert from a J-1 visa to an H-1B visa and can then work for their employer for a minimum of three years, which usually can be easily extended to six years.
What are the advantages of H-1B visas?
As previously mentioned, IMGs who enter U.S. medical residencies on H-1B visas do not have to return to their home countries for two years. An H-1B visa is sponsored by an employer. The residency program acts as the IMG’s first employer in the U.S., but when IMGs complete training they can be sponsored by another employer, such as a community health center. The health center does not have to be in a shortage area, which is another advantage of the H-1B.
While working for a health center on an H-1B, IMGs can begin the process of obtaining a green card, allowing them to stay in the U.S. permanently. There is an annual cap on the number of H-1B visa petitions the federal government will approve each year and it is important to know if this quota has
been filled when preparing to submit a petition on a physician’s behalf. A competent immigration attorney should be able to offer advice regarding when to file H-1B petitions and how to cope with the cap.
What does it take to get a green card in the U.S.?
There are several approaches to obtaining a green card and sometimes the process can be complicated.
However, a standard approach is to go through “Labor Certification.” This is a process by which the employer shows that it has tried to hire a U.S. physician for the position without success. The employer must advertise the job in a major national publication, such as Journal of the American
Medical Association or a major medical specialty publication, then review all the applications that come in to make sure no qualified U.S. applicant is available.
Another method is through the “National Interest Waiver.” In this process, the employer or physician must demonstrate that the health center is in a federally designated HPSA or MUA. National Interest Waivers are intended to make it easier for underserved areas to recruit physicians and can
reduce processing times to less than a year. At present, the government is maintaining that only primary care physicians can obtain a National Interest Waiver, though my firm is challenging this assertion in federal court.
IMGs who obtain green cards through a National Interest Waiver must practice in underserved areas for five years.
There are several other methods for obtaining a green card. The IMG might have a U.S. citizen relative, or he or she may qualify for permanent residence as a “person of extraordinary ability.” Physicians also may obtain a green card by marrying a U.S. citizen or by winning the annual “visa
How long does it take to get a green card?
For the most part, there are no processing backlogs for physicians seeking to obtain green cards. However, due to percountry green card quotas, there are significant backlogs if the physician was born in either India or Mainland China.
What about Canadian physicians?
Canadian physicians have a comparatively easy path to immigration, provided they have passed a U.S. qualifying exam (USMLE, FLEX or NBME). With a U.S. exam, Canadian physicians may obtain an H-1B visa in as little as 15 days through an offer of employment. This is contingent upon
their obtaining a medical license in the state where they will be practicing. Canadian physicians are licensable in over 40 U.S. states, so this is generally not a problem.
If Canadian physicians do not have a U.S. exam, they still can obtain a green card through an offer of employment in the U.S. (provided the group or other employer is located in a state that reciprocates Canadian licensure). This process may take several years, however.
Community health centers should note that foreign-born physicians they hire may have unique circumstances affecting their ability to work and live in the United States. Explore the situation thoroughly with a competent legal professional to ensure the immigration process is timely and efficient.
Carl Shusterman previously served as a trial attorney for the U.S. Immigration and Naturalization Service and now is principal of The Law Offices of Carl Shusterman, Los Angeles. For more information regarding physician immigration issues, visit: www.shusterman.com/ physiciansusimmigration.html.
Rules and Guidelines for Recruiting Foreign-Born Physicians