A quarter of the physician workforce in the United States consists of international medical graduates (IMGs). This year 4,222 non-U.S. citizens matched in first-year residency positions. I am an IMG from Guatemala, where I completed medical school. In March of 2014, I matched to an internal medicine residency in the United States. The road has been both satisfying and challenging, with all kinds of uncertainties. I have always been attracted to the countryside, and started my training at a large tertiary academic medical center in rural Pennsylvania on a J-1 visa (training visa).
IMGs mainly come to the United States on two types of visas – H-1B and J-1 visa (sponsored by the Educational Commission for Foreign Medical Graduates [ECFMG]). My wife and I opted for the latter due to work restrictions for her if I was on an H-1B visa. Some J visas carry the requirement of returning to your home country for two years after finishing your training before you are eligible to work in the United States [212(e) of the Immigration and Nationality Act]. Furthermore, some J visas carry the burden of annual renewal, depending on your duration of training. To renew the visa, you must leave the U.S. and apply at a U.S. embassy. When you re-enter the U.S., you also need to renew your driver’s license at the Department of Motor Vehicles. After I finished my residency, my family and I headed to New Hampshire so that I do an endocrinology, diabetes, and metabolism fellowship combined with a preventive medicine residency and a MPH degree.
One way to waive the two-year home country requirement, after completing the exchange program, is by doing a J-1 waiver through the Conrad 30 Waiver Program. Senator Kent Conrad formulated the Conrad 30 Program in 1994 to address the issue of physician shortages in rural and urban areas of the United States. This program allows each state’s Department of Health to sponsor 30 IMGs by having them serve in federally designated shortage areas. Because we like living in rural areas, and I am trained in public health and preventive medicine, with interest in caring for underserved populations, I thought this program was an excellent balance between my interests and serving a community in need. I interviewed for a job in upstate New York that qualified as a shortage area, signed the contract, applied for the J-1 waiver, and was fortunate that the New York Department of Health recommended me to the Conrad 30 program. My family and I celebrated on that day, thinking this was the end of a long and nerve-wracking process. But this was only one of the steps that will allow me to provide care to an underserved community in rural America. After each state’s Department of Health recommends a waiver, the application is forwarded to the U.S. Department of State (DOS) Waiver Review Division (WRD) for appropriate action. The DOS-WRD then notifies the U.S. Citizenship and Immigration Services (USCIS) of its recommendation. USCIS makes a final determination on whether to approve or deny the waiver application, at which point you are able to switch from a J-1 to a H-1B work visa, and start the job where you signed your contract. This process normally takes many months and hiring an attorney.
During the COVID-19 pandemic, the time for approval has extended, placing IMGs and their families in a particularly difficult and vulnerable position. Some of the recent concerns raised by IMGs include how the introduction of telehealth affects meeting some of the J-1 waiver requirements for those who are already in the waiver program. For IMGs who are starting their residency or fellowship training, there are now delays both in scheduling visa interviews at U.S. Embassies and in the processing time of their visas. Realizing that there is a great need for physicians in underserved communities, national organizations such as the American Medical Association are advocating to expedite this process. The USCIS issued a policy memorandum that introduced temporary policy changes regarding full time-work requirements and provision of telehealth services. For those who are starting their residency training, ECFMG has been working with the U.S. DOS to communicate concerns related to COVID-19 and IMGs participating in residency or fellowship programs.
Many IMGs, like myself, are facing challenges related to the visa application, immigration status, and waiver programs, amongst others. I strongly believe this population of resilient physicians should be continued to be supported more than ever. This will not just help us feel more certain for our own and family’s futures, but allow us to care for patients in times of unprecedented need. In my case, I will complete fellowship training at the end of June 2020 and am eager to practice as an attending in an underserved area in New York State. However, my wife and I have no option but to stay and wait in the granite state with our two U.S.-born daughters until our paperwork is complete.
Juan J. Delgado-Hurtado is an internal medicine physician.
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