Goulder Immigration Law Firm

Visas for Physicians

Basic Physicians Visas---an Introduction to J visa waivers, H-1B status and permanent residence for physicians in the U.S.

According to the American Medical Association (AMA), over 20 percent of all active physicians today are international medical graduates ("IMGs") and in some specialties are comprised of over 30 percent IMGs. An increasing number of IMGs are U.S. citizens, however the majority are foreign national physicians for whom contending with U.S. immigration laws can be confusing.

The complexities of U.S. immigration law means each physician’s case may be different. Nonetheless there are general terms and concepts IMGs and their employers should be familiar with if they want to negotiate their way through the maze of existing rules and regulations.

Basic requirements. IMGs need the following in order to practice medicine in the United States: 1) A degree from a foreign medical school. 2) An Educational Commission on Foreign Medical Graduates (ECFMG) certificate showing the physician has knowledge equivalent to that gained at a U.S. medical school. To obtain an ECFMG certificate, IMGs must pass the U.S. Medical Licensing Exam (USMLE) Parts 1 & 2, pass an English exam, and pass the Clinical Skills Assessment (CSA) exam.

J waivers. Many IMGs come to the U.S. to train on Exchange Visitor Visas or "J visas." This type of visa requires the holder to return to his home country for two years before being able to practice medicine in the U.S. An exception to this rule may be obtained if a U.S. government agency will sponsor the IMG for a J waiver. Over 1,000 IMGs are sponsored for J waivers each year. In general, employers must be located in federally designated Health Professional Shortage Areas ("HPSAs") or Medically Underserved Areas ("MUAs") to obtain waivers for J visa holders, and the physician must practice primary care or psychiatry. However, the Veterans Administration (VA) sponsors both specialists and primary care physicians in its facilities across the U.S.

Sponsoring agencies. Several federal agencies currently sponsor IMGs for waivers. These include the Appalachian Regional Commission (ARC), the Department of Health and Human Services (HHS), and the VA. Each federal agency still sponsoring J physicians has its limitations. ARC only sponsors J physicians in some 13 Appalachian states, while HHS sponsors some 200 J physicians annually in research positions and has recently started sponsoring a few primary care physicians. The VA only sponsors physicians directly employed by one of its facilities.

The "Conrad 30." This program allows any state to sponsor up to 30 IMGs for J waivers each year. Almost every state participates in the program. Like the federal program, IMGs must work in HPSAs or MUAs, but not all states require that they practice primary care or psychiatry. The Conrad 30 program is an increasingly attractive option for IMGs seeking J waivers in light of decreasing federal funding.

H-1B visas. The H-1B is an employer-sponsored temporary work visa for foreign professionals, allowing IMGs to live and work in the U.S. for up to six years. Some IMGs attend U.S. residency programs on H-1Bs, with the residency program acting as the sponsoring employer. In contrast to J-1 physicians, who only need USMLE Parts I and II to work as residents, IMGs with H-1B visas must have completed all three parts of USMLE, or have completed Federation Licensing Exam (FLEX) or the National Board of Medical Examiners (NBME) exam. Before filing for an H-1B, physicians must be licensed in the state of intended employment.

The employer must file a Labor Condition Application with the U.S. Department of Labor and, subsequently, an H-1B petition with USCIS. The number of persons who may be sponsored for H-1B status is limited to 65,000 annually. The numerical cap is reached earlier each year. H-1B petitions must be filed before April 1 of each year. Visas are not issued until October 1 of that year. H-1B employment is unauthorized prior to the visa issuing.

Some hospitals, university affiliated teaching hospitals and certain non-profit entities are cap exempt. Cap exempt employers can file their petition at any time throughout the year and as the employer is cap exempt the visa can be issued by USCIS shortly thereafter. The beneficiary physician can begin employment when the visa is issued.

Permanent residence ("green card").

IMGs in H-1B status may file for permanent residence or a green card if they wish to stay in the U.S. indefinitely. There are a number of ways IMGs may obtain green cards and the appropriate strategy will depend on each IMG’s particular circumstances. What is important to remember is that IMGs on H-1B visas must obtain green cards before the H-1B expires. If they do not, they may fall out of legal status and be unemployable.

O visas. The O visa is commonly referred to as the "Super Star" visa, because it is granted to physicians and other professionals who can demonstrate "extraordinary ability" in their fields. For a physician, this means multiple publications and citations demonstrating preeminence in a particular area. The threshold for demonstrating extraordinary ability is very high.

Canadian physicians. Canadian-educated physicians are not considered IMGs. They may obtain medical licenses in most U.S. states and obtain green cards based on their Canadian training and exams. However, they cannot obtain H-1B visas unless they have completed a U.S. qualifying exam, either the USMLE, NBME, or FLEX. Canadian physicians who have completed a U.S. exam can obtain H-1B visas and work in the U.S. in a matter of weeks. However, those who do not have a U.S. exam may have to wait up to two years to obtain a green card.

Strategies. For most IMGs, the road to a green card lies through an offer of employment—in particular, employment with a medical facility in an underserved area, if the IMG needs a J waiver. There are various organizations, publications, recruiters and web sites that list jobs. IMGs seeking waivers should identify hospitals in HPSAs and MUAs and contact them directly about employment.