American College of Physicians: Internal Medicine — Doctors for Adults ®


Residents, programs try to finesse complex visa issues

Like programs trying to fill training slots, IMGS who want to come to--and stay in--the U.S. face many touch choices

From the July-August ACP Observer, copyright 2006 by the American College of Physicians.

By Yasmine Iqbal

This November, Hasan Jafri, MD, will begin a hematology/oncology fellowship four months after the official start of the program—the second time that international red tape has delayed his training in the U.S.

In March 2003, Dr. Jafri was in his home country of Pakistan when he learned that he had matched in internal medicine at Indiana University School of Medicine in Indianapolis. He immediately applied for a J1 exchange visitor visa, expecting the paperwork to come through well in time for him to begin the program that summer. Instead, his first request was denied—an example of how complicated visa issues can become for international medical graduates (IMGs).

The U.S. embassy did grant his second visa request, but then told Dr. Jafri he'd have to undergo a security clearance. By the time he cleared that hurdle, he wasn't able to join his fellow interns until November.

“I was lucky my program could afford to start me late," he said. "I know other people who lost their residency slots because of delays.”

With internal medicine residencies increasingly relying on IMGs, programs across the country this month are scrambling to keep positions open for first-year residents delayed due to visa problems.

Even when the visa-application process goes smoothly, the choice of which visa to apply for is a complicated one. At the same time, programs have to decide which visa best meets their own quality standards and time constraints.

Visa choices, challenges

Internal medicine residency programs in the U.S. are grappling with visa issues for one key reason: Programs increasingly depend on IMGs to fill slots.

According to figures released by the National Resident Matching Program in March, only 56.3% of internal medicine Match slots this year were filled by U.S. seniors. That's in addition to the many IMGs who find positions outside the Match.

"When you combine those with the residents who stay in [the Match], IMGs probably make up the majority of internal medicine residents,” said Herbert S. Diamond, FACP, Governor for ACP’s Pennsylvania Western Chapter and chair of medicine at Western Pennsylvania Hospital in Pittsburgh.

IMGs may be tempted to take positions outside the Match to get an early jump on visa arrangements—and may feel pressure to settle for a program that is not their first choice. They know that programs might not rank them if they refuse to take an offered slot, putting both their training and visa status in jeopardy.

“There are definitely cases of programs using before-Match offers of a residency position with a H1B visa to 'cherry pick' the best graduates," Dr. Diamond said, "although putting this kind of pressure on IMGs is absolutely wrong.”

The vast majority of IMGs with visas have either a J1 exchange visitor visa or an H1B temporary worker visa. (See "A snapshot of IMG status.") The choice of which to apply for depends on many factors—and will influence career and living decisions for years to come. (See "Tough choice: an H1B or a J1?")

Program directors likewise have to decide what kind of visas they want to deal with. In general, J1s are easier to handle because those visas are sponsored—and administered—through the private nonprofit Educational Commission for Foreign Medical Graduates (ECFMG), not through the training institution itself. But because academic centers are exempt from the current H1B visa cap, more residents are seeking H1Bs—and more programs are willing to act as sponsors.

According to data published in the Sept. 1, 2001, and the Sept. 7, 2005, issues of Journal of the American Medical Association, the number of residents on H visas (which include H1, H1B, H2 and H3 visas) rose between 2000 and 2004 from 1,599 to 2,878, jumping from 6.5% to 10.8% of the total number of IMGs in accredited and combined specialty programs.

Conversely, the number of J1 visa residents (as well as J2 exchange visitor visas) dropped from 6,619 to 3,841 over the same period, a percentage decrease from 26.8% to 14.4% of IMGs.

Ethan D. Fried, FACP, director of graduate medical education at St. Luke's-Roosevelt Hospital Center in New York, noted that although J1 residents present fewer logistical challenges, H1B residents might offer more qualifications and experience. To get an H1B, IMGs are required to complete all three steps of the United States Medical Licensing Examination. J1 visa holders, on the other hand, have to complete only steps 1 and 2.

“H1B visa residents definitely add to the quality of our program,” he said.

But they come at a price, observed Michael A. Weisz, FACP, internal medicine program director at the University of Oklahoma-Tulsa. The program currently has 10 H1B residents out of a total of 51 internal medicine residents. With H1B sponsorships taking three months or longer to process, “as soon as the Match is over, we’re on the clock so our residents can start on July 1," he said. "This is a huge hassle."

To avoid delays, said Dr. Weisz, the university has staff dedicated to assisting residents file their H1B visa paperwork correctly and tracking the status of their applications, so problems can be addressed immediately.

According to Dr. Fried, residents can pay a $1,000 “premium processing” fee to ensure a two-week processing turnaround—an expense the hospital strongly encourages them to bear. Costs are also an issue for the hospital, he noted: The H1B visa processing fee is $679 for not-for-profit institutions and $2,179 for for-profit entities.

And St. Luke’s-Roosevelt has gone a step further: It contracts with an immigration attorney who works with all H1B visa residents to guide them through the application process.


“Using a single, really good lawyer definitely saves time,” said Dr. Fried, who knows firsthand how costly delays can be. One resident accepted for 2006-07 was late calling the U.S. Embassy to get his H1 visa stamped—and ended up with a Sept. 27 appointment. That was bumped up to July 3 only after Dr. Fried wrote a “long, pleading letter” on his behalf.

“Latecomers disrupt the schedule” he said. “People miss out on electives, we use up our jeopardy [sick call] pool, even people’s vacations have to be put off.”

Afraid to go home

One reality is the same for both H1B and J1 visa holders: Visas do not guarantee residents the ability to easily travel to and from their home country. Even a short vacation might turn into an unexpectedly long break.

“Once they’re in the U.S., we really discourage residents from leaving, even though we realize this probably adds to their stress by taking away their support system,” Dr. Fried said. One resident who took a vacation to visit his family was delayed so long by a U.S.-required security clearance that he had to take a one-year deferral, and Dr. Fried had to hire another resident to fill his slot.

The problem, which was especially acute after Sept. 11, may be easing in recent years. Even so, residents from Pakistan, India, China and Middle Eastern countries report that they are afraid to leave the U.S. for fear that they won’t be able to return.

“The moment they go back, they know they will have to go through a security clearance, and this can take months,” said Shakaib U. Rehman, FACP, a member of ACP’s IMG Task Force and associate professor of medicine at the Ralph H. Johnson V.A. Medical Center and Medical University of South Carolina in Charleston, S.C. “I know people who haven’t gone home for seven or eight years, until they got their green cards.”

For Dr. Jafri, who is beginning his fellowship at Louisiana State University Health Sciences Center in Shreveport, it's been almost three years since he's been back home to see family. “It’s really tough," he said, "because I have no immediate family in the U.S.” Many programs offer IMGs resources to help cope with isolation. St. Luke's-Roosevelt, for instance, offers counseling services, after-work happy hours, potlucks and assigned mentors.

Worth the hassle?

Even though the number of visa applications have not declined, processing problems are leading more IMGs to seek placement outside the Match, said Dr. Weisz, in the hope that it will allow them to begin the visa process sooner.

At the same time, “I know many graduates who are deciding that the training isn’t worth the hassle—and a lot of them are extremely talented candidates," said Mubashir Khan, ACP Associate Member, chief resident at Methodist Hospital of Indiana University in Indianapolis and a member of ACP's Council of Associates.

And IMGs who do finish their training here are realizing they have global options.

“There’s a lot more competition internationally for these doctors than there used to be,” particularly from Australia, Germany and the United Kingdom, said Gregory Siskind, JD, an immigration lawyer based in Memphis, Tenn. “Other countries have put all sorts of immigration policies in place to attract U.S.-trained physicians, so more IMGs are simply going elsewhere after their residencies.”

Yasmine Iqbal is a freelance writer in Philadelphia.


Tough choice: an H1B or a J1?

Choosing an H1B ....

By the time Sameer Badlani, ACP Associate Member, entered residency at the University of Oklahoma-Tulsa, he had already completed two years of a residency program in his home country of India. He had also completed all three steps of the United States Medical Licensing Examination, making him eligible for an H1B visa.

Now a member of ACP's Council of Associates, Dr. Badlani chose the H1B over the J1 because he thought it would give him a better chance of staying in the U.S. after he completed his residency. But it wasn't an easy decision.

“A J1 visa would have been easier to get, and I heard that I’d have a harder time getting a fellowship on an H1B visa,” he said. That's because most fellowships are funded by the National Institutes of Health (NIH) or other government agencies—which don't accept H1B visa applicants. "I’d be eligible only for fellowships that would be privately funded."

On the other hand, he'd also heard of physicians who’d spent up to seven years in the J1 visa waiver program to stay in the U.S. to practice. "That really influenced my decision,” he said. “Even so, there are no clear guidelines for which visa to get. You talk to your friends, you talk to your professors—and then you just go for it.”

When his residency ends this summer, he will be joining the University of Chicago as a hospitalist, clinical instructor and informaticist. His new employer will continue sponsoring his H1B visa, allowing him to start the two- to five-year process of applying for his green card.

Still, he said, it's been a long and frustrating experience. “I’m not saying that physicians should be granted citizenship as soon as they enter the country,” Dr. Badlani said. “But to keep making the process harder, more confusing and restrictive after they’ve spent years proving themselves makes no sense.”

... or a J1

Mubashir Khan, ACP Associate Member, chief resident at Methodist Hospital of Indiana University in Indianapolis, would like to have the option of continuing his career in the U.S. after his J1 visa expires in three years.

He plans to complete a gastroenterology fellowship at Indiana University—and then he and his wife, a critical care fellow at the same institution, must return to Pakistan to fulfill the two-year J1 visa home return requirement. Or they can apply to one of the J1 visa waiver programs, which allow J1 visa physicians to continue their careers in the U.S. if they practice in a medically underserved area for at least three years.

Dr. Khan, who is also an ACP Council of Associates member, knows that J1 waiver jobs have become very hard to get.

Each state has only 30 statewide-sponsored ones to offer every year—and the only federally sponsored program (now run by the Department of Health and Human Services, which took over from the Department of Agriculture) placed only four physicians in J1 waiver jobs in 2005.

Dr. Khan knew he would have had a better chance of staying in the U.S. if he had applied for an H1B visa at the start of his residency. But he felt he had a better chance of obtaining a fellowship with a J1 and not running up against NIH-funding requirements.

At the same time, he knows many people who chose programs and fellowships based on the program’s willingness to sponsor an H1B visa, even if the physicians would have preferred to go to another institution.

“In a perfect world, people shouldn’t choose a career path based on a visa,” he said. “In reality, it carries a lot of weight.”


A snapshot of IMG status

As of Aug. 1, 2004, the citizenship and visa status of all residents who were international medical graduates (IMGs) in U.S. training programs was as follows, in percentages:

visa status
% of total IMG
Native U.S. citizen 13.6%
Naturalized U.S. citizen 10.6
Permanent resident 24.5
B visa holders 0.3
F-1 student 0.4
H visa holders 10.8
J visa holders 14.4
Refugee/asylum 0.4
Other 2.1
Unkown 23.0

Source: Journal of the American Medical Association, Sept. 7, 2005


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