Working in the United States:
Resources for the International Neurologist
Secondary school…post-secondary school…medical school and licensing…internships…residencies and fellowships―nothing about the neurologist’s journey from training to practice is easy, but for the immigrant physician wishing to work in the United States, there are even more challenges. Sometimes, there’s a repetition of training or licensing to meet US criteria; often, there are language or cultural barriers. And nearly always, there’s a series of steps to obtain visas or waivers that provide eligibility for employment.
While many foreign-born neurologists first arrive in the US on a J-1 visa to complete a residency or fellowship, they soon find the process for remaining here as practicing physicians to be more complex. If this describes you, the good news is that there are multiple ways to become approved to work in the United States. But every path takes patience and attention to detail. Read on for more information and check out the glossary to learn more about the terms you’ll want to understand.
More than one way to work in the US
When someone talks about getting permission to stay on in the United States, they may be thinking in generic terms or they may be thinking about just one process they’ve heard about. In truth, there are several ways for foreign-born physicians to work in the country, each requiring its own strategy and process. The following three options are perhaps the most common:
J-1 Visa Waiver. Neurology fellows and residents using a J-1 visa to complete their studies in the United States are required to return to their home countries for two years when the visa expires, before applying to re-enter the United States. To set aside this requirement (allowing them to continue directly to employment without returning home), they need a waiver or, more specifically, what’s known as the Conrad 30 J-1 visa waiver. This particular section of the waiver program provides 30 slots per state specifically for physicians. To receive one of these slots, the physician’s potential employer makes application to the state’s department of health requesting the two-year home residency be waived in return for the physician providing three years of health care in a medically underserved area.
H-1B Visa. Since H-1B visas don’t include a specific program for physicians, approximately 85,000 annual slots are shared among all professions, attracting around 200,000 applicants. Universities and training programs are usually exempt from the cap, meaning foreign-born physicians in training don’t need to compete for limited slots―until they finish training, that is. At that point, they will either need to enter the broader pool, or focus on employment with exempt training institutions. In both cases, employer sponsorship will be required for the visa to be approved. Unlike the Conrad J-1 visa waiver, the H-1B visa does not require employment in a medically-underserved area.
Permanent residency/US citizenship. For physicians who want to live and work permanently in the United States, the most secure route will be through permanent residency, leading to citizenship. In this case, residency, often called Green Card status, would be achieved through an employer-sponsorship process. After three or five years of permanent residency, the physician would be eligible to apply for what is called “naturalization”―the term for becoming a citizen of the United States.
If all of this sounds overwhelming, take heart. Ann Massey Badmus, principle attorney with Badmus & Associates in Dallas, has some good news: In her practice specializing in immigration issues, she says, “I talk to two or three hundred physicians a year and I would say 90 percent or higher would get approved.” Badmus identifies three keys for success in the process: Understand the type of visa you’re seeking and what it requires; start as early as possible mapping out your strategy; and speak with an immigration attorney as early in your career as possible, to provide guidance. Read on for more on each of these points.
Timing is important―steps to take
Whatever you’ve heard in the past about how long a visa approval might take, it would be smart to extend that timeline by several months or more. For numerous reasons, ranging from backlogs to rule changes to staffing shortages and an increase in applications across all programs, government-based visa processes are running much slower than in years past. Badmus recommends starting the process at least one year, and more likely two years in advance of when the physician would want to be employed. That means a doctor starting a two-year fellowship now should also immediately initiate the process to secure a visa for later employment.
As Badmus notes, “The earlier you start, the better your options” of finding work you want in a region you want to live in. Since both J-1 visa waivers and H-1B visas require employer sponsorship, it’s logical to start the process with a job search. But that’s actually the second step, at least in the case of the Conrad 30 program. Because each state has 30 slots for physicians seeking a J-1 waiver, Badmus advises a look at the program requirements and deadlines for the states you’d most want to work in. With that knowledge in hand, you’ll be better able to gauge which employers to contact and how quickly. (See the resources list below for a link to a list of each state and its requirements.)
Ideally, Badmus says, a physician would be through interviewing and have an employment contract before starting the last year of fellowship “because you’re going to need that last year to work through the J-1 visa waiver process.” The contract itself will be similar to any other employment contract with the exception that three years will be stipulated. Depending on the state, the contract may also leave out the standard non-compete clause, as states providing the J-1 waiver would prefer doctors are able to continue working in the underserved area if they choose.
Strategies to employ
While it’s natural to begin your search where you’d most like to live, that might not be the most strategic path. For J-1 visa waivers, remember that highly popular and densely populated states such as California and New York have the same 30 slots as states such as North Dakota and Idaho―so it’s easy to guess which spots might be the most or least competitive. If your choices lead you to more competitive locations, you might need additional strategies, such as a willingness to be a generalist or work in a different kind of practice than you’d envisioned. The key, Badmus says, is to study the needs of your target states as well as their requirements and process, then adjust your own process and expectations accordingly. And, if you get turned down in the first state you try, Badmus advises applying in other states.
For those seeking H-1B visas, similar cautions apply. Employers in very popular parts of the country may be flooded with applicants seeking visa-sponsored positions, while those in rural or under-served areas may have far fewer applicants.
For both types of visas, the success strategies for any job search would apply: Identify the employers you would like to work for, send your CV to their recruiters or practice managers, request a meeting or interview, etc. The difference for a candidate seeking a visa sponsorship, however, is critical: Since you are asking the employer to take an extra step on your behalf, you need to be prepared for that part of the conversation. As Amy Schoch, senior manager of AAN Career Services, notes, “You can’t wait for the employer to do the work for you. If you want your first choice for employment, you’ll need to do some of the steps yourself.” That could mean supplying information and contacts for the visa program, completing some of the forms in advance, arranging a conversation with your attorney to answer questions, or anything else that makes the process of hiring you less intimidating for the employer.
What if you can’t secure employment before your training ends, despite your best efforts? Two of the most common choices are to continue with another training program or return home to work for two years before attempting re-entry to the United States. You might also double down on efforts to identify cap-exempt employers (usually training institutions) for the H-1B process, although timing might not be on your side. Even when these options are exhausted, it’s possible that other pathways could be available, depending on your specific circumstances. This is one of many reasons to work with an experienced immigration attorney, to reduce the chances of missing an opportunity.
Don’t go it alone―you need a team
It’s probably clear by now that immigration processes and visa applications are not simple procedures. This is a situation that calls for a team of experts, not a solo effort. In addition to mentors, advisors, and others who might assist, your team needs two key people: An attorney and a recruiter. The recruiter slot can perhaps be filled by a rotating set of professionals you contact in each hospital or practice you want to work at. Or, you might focus on a recruiting firm specializing in physicians or neurologists for the expertise you need. In either case, the recruiter is key to helping you understand the needs of different employers and strategies for approaching them.
By contrast, your attorney would ideally be someone you choose early in this process, who continues to serve you throughout your career. Because visas are federal, it won’t matter which state your attorney is licensed in. But it does matter that he or she specializes in immigration and, most importantly in immigration for physicians. This is the person who can advise you not only on the appropriate steps to take, but on the terms of your contract and other details relating to your employment. It’s common for attorneys to meet briefly at no charge, but then the services will be billable, either by the hour or per service. Given the high stakes involved, this is a cost most physicians consider to be part of the investment they’ve already made in their training.
For further information, check out the glossary and resources list below. Then get started! Time will slip past before you know it, and this is a process you want to tackle as early as you can.
UNDERSTANDING THE OPTIONS―A GLOSSARY OF TERMS
The first step for candidates is to gain a basic understanding of the options available to foreign-born physicians who want to work in the US. While each situation is different and needs its own solution (best identified by a qualified attorney), these are the relevant visa options both candidates and employers should know about:
F-1 visas are used by foreign nationals who come to the United States for enrollment in medical school or other full-time education.
J-1 visas are used by foreign-born physicians (or other professionals) who attained their medical degrees in their home countries before coming to the United States to complete residency or fellowship training.
J-1 visa waivers are needed for foreign nationals to stay on in the United States to apply for work. The Conrad 30 waiver is the specific J-1 visa waiver for J-1 foreign medical graduates (FMGs). Without the waiver, the candidate must return to his or her home country for two years before being eligible to come back to the US.
H-1B visas are the most common work visas used by foreign-born physicians (and others with bachelor’s degrees or higher) who seek employment in the United States. These visas must be sponsored by employers, and the physician must be licensed as well as degreed.
Additional visas, such as O-1, TN or E-2 visas, may also be applicable in more extraordinary situations to foreign-born physicians seeking work in the United States.
All visas noted above are temporary work or education visas and must be renewed according to their specific criteria.
Permanent residency (“Green Card” status) can be gained through several pathways, including employment. In this circumstance, the process must be sponsored by an employer.
US citizenship normally requires a period of three or five years of permanent residency before one is eligible to apply for naturalization as a United States citizen.
Government resources and websites: In addition to webinars, the website for Badmus & Associates includes a helpful list of immigration-related websites leading to government resources and case-status sites. Check it out at badmuslaw.com/resources/helpful-links/.
State-by-state Conrad J-1 visa waiver timelines: To help you track the deadlines and steps for the Conrad J-1 visa waivers specific to foreign-trained medical professionals, the Ford Murray Law firm has created a state-by-state reference on its website. Visit it at fordmurraylaw.com/must-know-deadlines-conrad-30-j-1-visa-waiver/.
Books and articles: Numerous law firms and attorneys have written helpful guides on immigration steps for physicians and others, including Ann Badmus. Her book, The Immigration Prescription: The Practical Guide to US Immigration for Foreign-born Physicians, can be purchased in print or as a Kindle ebook.