Who is an International Medical Graduate?
An International Medical Graduates (IMG) or a foreign physician is a physician who received his/her medical degree outside the U.S. or Canada.
What are the initial steps to be undertaken to practice medicine in the USA?
An (IMG) begins the journey of immigrating to the United States by first seeking certification from Education Commission for Foreign Medical Graduate (ECFMG). In order to be certified by ECFMG, the candidate must pass tests on performance on medical science and clinical skills examinations—USMLE Step 1, Step 2 Clinical Knowledge (CK), and Step 2 Clinical Skills (CS) and also submit the necessary documents for primary-source verification of the IMG’s medical education credentials, including the final medical diploma, final medical school transcript, and transcript(s) to document transferred academic credits.
Upon getting the ECFMG certification, IMG then proceeds to seek accredited residency training program in the U.S- this process will take at least three years. The physician will have to complete a residency program regardless of the training they have received overseas. Many medical graduates are placed in residency programs through the National Resident Matching Program.
Typically, IMGs complete the medical residency program under the J-1 visa category. ECFMG is authorized by the U.S. Department of State to sponsor J-1 Exchange Visitor physicians enrolled in accredited programs of residency and fellowship. ECFMG is the sole sponsor of J-1 physicians in clinical training programs
However, pursuing medical residency on a J-1 visa comes with one really important condition. [§212(e) of the Immigration and Nationality Act, as amended] requires that J-1 physicians and accompanying J-2 dependents reside in the home country for an aggregate of at least two years before being eligible for certain changes or adjustment in visa status in the United States.
IMG may pursue residency program in an H-1B temporary worker status, if the residency program is willing to sponsor an H-1b visa. The big advantage would be the IMG will not require a waiver from home residency requirement. But he disadvantage is that the physician would have used up 3 out of 6 years to complete the residency program, and if he/she wants to pursue a fellowship or additional program, they may run out of time to get the green card process rolling.
How to avoid 2 years of home residency requirement
Upon completion of the medical residency, IMGs are faced with the option of either going back to their home country for two (2) years, or continue to work in the United States. If they chose to work in the USA, they do have option to seek waivers from the United States Government for allowing them to continue to work in the USA.
The waiver could be on the basis of:
- Proving their departure from the United States would cause exceptional hardship to a US citizen relative of the IMG such as spouse or children;
- Proving that the IMG cannot return to his or her home country due to fear of persecution by the government or other parties in his/her home country, of The prospect of obtaining a waiver from the US State Department on the basis of these extreme requirements is therefore fairly remote for most FMG’s.
- Agreeing to work in the United States in a medically underserved area (MUA), or a health professional shortage area (HPSA) on an H-1b visa for a period of three (3) years.
Majority of the physicians chose option 3 of working in a medically underserved area for a period for three (3) years. Some highly qualified physicians who can show outstanding achievement in their field of medical specialization may be eligible to seek an O-1 visa and continue to work anywhere in the United States. However, at some point in time they have to get a waiver from two (2) years of home residency requirement, or else they will never able to obtain Legal Permanent Residency Status) aka green card.
How to seek waiver by agreeing to work in a Medically Underserved Area?
The process of seeking a waiver begins with the IMG identifying the geographic location of intended employment. The process should ideally during the end of 2nd year of residency program. Majority of the IMGs seek the waiver process under the Conrad-30 state waiver application program. Under his program, each state can have up to 30 slot for physicians to come and work in medically underserved area. Although each state has developed its own application rules and guidelines, the following program requirements apply to all J-1 medical doctors.
The J-1 medical doctor must:
- Agree to be employed full-time in H-1B nonimmigrant status at a health care facility located in an area designated by U.S. Department of Health and Human Services (HHS) as a Health Professional Shortage Area (HPSA), Medically Underserved Area (MUA), or Medically Underserved Population (MUP).
- Obtain a contract from the health care facility located in an area designated by HHS as a HPSA, MUA, or MUP
- Obtain a “no objection” letter from his or her home country if the home government funded his or her exchange program
- Agree to begin employment at the health care facility within 90 days of receipt of the waiver, not the date his or her J-1 visa expires.
It is very important to note each states’ application process and also verify the start date of the application process. Majority of the states require the physician to practice as a primary care physician, but some states may allow specialists.
The application for a Conrad 30 waiver is not simple. The process involved working with the Department of State, USCIS and most importantly the given state’s healthcare department. Most states require a significant amount of evidence to support the waiver application and some require the payment application fee. The process starts with seeking an application number from the Department of State, then submitting an application the state’s department of health with all the evidence such as the physician’s qualification, his medical license, the proof from the employer that they fall under Medically Underserved Area or serve Medically Underserved Population, some evidence related to difficulty in hiring US physicians in that community, an employment contract between the employer and IMG that has special provisions related to the waiver requirements, the fee schedule,etc. Once the state approves the application and grants the IMG one of the coveted 30 slots, the state health department forwards the application to the Department of State for their favorable recommendation. Upon receiving the favorable recommendation from the Dept. of State, the case gets forwarded to the USCIS, and they approve the waiver. Once the waiver is approved, employer/IMG can move on the last stage of filing the filing the “H-1b” application with the USCIS.
IF for some reasons, Conrad 30 Waiver process is not available or the 30 slots gets filled out, they may be other Interested Government Agencies such as U.S. Human and Health Services (HHS), Appalachian Regional Commission, Department of Veterans Affairs, The Delta Regional Authorities that can review the waiver application filed on behalf of the IMG, and forward it to the Department of State.
The H-1b application with the USCIS
Upon approval of the waiver application (Form I-612), the employer will submit an H-1b petition to the USCIS, and the H-b is for a period of three (3) years. During the IMG’s employment, the employer can commence on processes that would lead to the eventual grant of the Legal Permanent Residency or “green card” to the FMG. But IMG can only file for the Legal Permanent Residency after completing three (3) years, the FMG can then file for the “green card”.
It is long journey for a foreign physician to finally end up with a working visa. Though an attorney’s help is not required at the initial stage of seeking residency program, it is highly recommended that the IMG seeks the assistance of an experienced immigration attorney to navigate the waiver process that would successfully lead to an H-1b visa and later clear the path to Legal Permanent Residency.