June 30 marks a pivotal juncture in a doctor's journey, as it is when most finish their medical residency and fellowship training across the United States, permitting them to transition into medical practice.
For an International Medical Graduate (IMG)—a doctor who received medical education from a medical school located outside the US or Canada—this date is even more critical, as the US immigration system needs to run smoothly to permit these IMGs to transition into practice after completing their medical residency and fellowship training. If the US immigration system fails, these IMGs are forced to depart the country, causing significant burdens to both the IMG and our healthcare system alike.
Requirements for Medical Practice
To practice medicine in the US, IMGs must receive certification from the Educational Commission for Foreign Medical Graduates (ECFMG) by completing the first two steps of a three-step United States Medical Licensing Examination (USMLE).
Additionally, IMGs must meet certain requirements before they are eligible for the required license to practice medicine. In most states, IMGs, whether they are US citizens or not, must complete at least one year of accredited graduate medical education (ACGME) in the country before they may obtain an unrestricted state medical license. Some states require two or even three years of ACGME training.
While there is a movement across the US to introduce alternative pathways to licensure for IMGs by removing or reducing the overall ACGME training requirements, the lack of immigration modernization for IMGs remains a significant roadblock.
Currently more than 15 states have passed or are considering legislation to establish alternative pathways to licensure for IMGs. Because medical licensing requirements are governed by state laws, IMGs need to verify the licensure requirements for the state they plan to practice in ahead of time to ensure they meet all requirements.
The Immigration Timeline
Most IMGs who receive medical training in the US do so on a J-1 visa, which requires a two-year home residency under section 212(e) of the Immigration and Nationality Act. This legal requirement means that all US-trained physicians in J-1 status must either return to their home country for two years after they complete their training programs or obtain a waiver of their residency requirement before they are eligible to pursue H-1B status to work in the US and pursue permanent resident status.
The process to qualify for a J-1 waiver is long and time-consuming, imposing additional burdens on IMGs in their journey to practice medicine in the US.
First, IMGs must obtain a job offer months to a year earlier than their US-educated counterparts, because a J-1 waiver requires employer sponsorship. IMGs commonly pursue J-1 waivers from either state departments of health through the Conrad 30 program, or from interested government agencies such as the Department of Health and Human Services (HHS) or regional commissions. Each state's Conrad 30 program has 30 J-1 waiver slots available each year, and almost half of the states in the US receive more than 30 J-1 waiver applications each year, making this lengthy process even more stressful and a real barrier to entry for many IMGs.
Applying for a J-1 waiver is a three-step process:
- Obtain an initial recommendation from the state Department of Health or another interested government agency. Each state and agency has different processing times, which can range from a few weeks to a few months.
- The initial recommending agency then sends the waiver to the Department of State's (DOS) Waiver Review Division (WRD) for recommendation to the United States Citizenship and Immigration Services (USCIS). Current DOS processing times range between two and six months.
- The DOS' WRD sends the waiver to USCIS for final approval of the waiver. At the time of this writing, USCIS states processing times for J-1 waivers, excluding hardship and persecution waivers, are estimated at four weeks.
This entire process, including the time it takes to prepare a J-1 waiver application, can take many months from initiation to final USCIS approval. The IMG must then obtain USCIS approval of H-1B status to start employment. As such, beginning early is key to ensuring minimal interruptions for IMGs seeking to practice medicine in the US.
The J-1 waiver simply prevents the need for an IMG to return home for two years in exchange for full-time work in underserved rural and urban communities. When there are delays at any of the three levels involved in the J-1 waiver process, it dramatically impacts the ability of the US Health Systems to employ these critically needed physicians to ensure access to healthcare in rural and urban underserved communities.
While advocates continue to press for modernization to the US immigration system for physicians, current laws have not been changed for more than 20 years. With this in mind, it is never too early for IMGs undergoing ACGME training to start educating themselves and preparing for the best J-1 waiver options early in their training programs.
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