The percentage of international medical graduates (IMGs) is higher in nephrology than in any other major subspecialty in internal medicine. IMGs accounted for 62% of nephrology fellows in 2017, compared with a nearly even split with American medical graduates (AMGs) in 2007.
Thirty-one percent of nephrology fellows, or half of IMGs in nephrology, are dependent on visas. This means that 1 in every 3 nephrology fellows requires an employer who can sponsor a work visa, either H1b or J1. Thus, the issues outlined here are not limited to a handful of nephrologists, and they have a major impact on the present and future of nephrology in the United States.
All the statistics listed in this article are from the American Society of Nephrology Workforce Survey, and these numbers have remained largely unchanged over the past 4 years.
For the uninitiated, H1B is a work visa, and J1 is an exchange student visa. Residency and fellowship programs may or may not support either form of visa for their trainees.
After training, fellows who require a J1 visa must work for 3 years in an underserved area before becoming eligible for permanent residency. The H1B visa does not come with such a restriction, but it has an 85,000 annual cap each fiscal year. Because the number of H1b applicants is usually higher than that, applicants go through a random lottery system.
In 2018, the United States Citizenship and Immigration Services accepted petitions for 5 working days, from April 2 to April 6, and reached the annual cap of 85,000 on April 6. This cap and lottery are not applicable if the employer is an institution of higher education or a nonprofit organization, making these employers much preferred by H1B workers. Once a physician is fortunate enough to find the right employer, an employment-based permanent residency, or green card, can be applied for.
The number of green cards available each year is limited. The majority are reserved for family-based categories, whereas a small fraction are available for the highly diverse group of employees trying to get permanent residency in the United States. There is a 7% per country limit, which means that no more than 7% of the visas for green cards may be issued to natives of any one country in a fiscal year, regardless of individual merit. As one can imagine, this puts immigrant physicians from large countries into an ever-increasing backlog for green cards.
This backlog is particularly large for citizens of India. India also happens to be the largest source of IMGs in nephrology; 81 of the 267 nephrology IMGs in the 2017 ASN workforce survey attended medical school in India. Currently, the wait time for an Indian physician to get a green card is anywhere from 20 to 150 years! In brief, these physicians will be visa-dependent for decades, and the issues outlined here are not temporary.
This green card backlog and chronic visa dependency have profound effects on nephrology, nephrologists, and their employers.
Impact on fellowships
It starts with fellowship applications. Because nephrology fellowships are relatively noncompetitive, more fellowship programs are willing to accept candidates requiring visas. This means that IMGs requiring visas have a higher chance of getting into reputable universities as nephrology fellows. This helps nephrology programs attract more visa-dependent applicants—but without permanent residency or citizenship, fellows do not have access to additional years of research on T32 grants. A T-32 enables institutions to make National Research Service Awards to individuals (U.S. citizens or permanent residents) selected by them for predoctoral and postdoctoral research training in specified shortage areas. Decades-long visa dependency also leads to ineligibility for National Institutes of Health grants during and well after graduation, making basic research even less attractive for IMG fellows and discouraging an ever-shrinking pool of trainees who are interested in pursuing nephrology research as a career path. This is surely a major reason why AMGs are significantly more likely than IMGs to report that they plan to continue their current fellowships (22.7% vs. 11.8%).
Clinical nephrology also presents several challenges for the IMG. An IMG with either an H1B or a J1 visa finds that the number of suitable job positions is limited. Employers are often not in desired locations, and 55.4% of IMGs reported having difficulty finding positions they were satisfied with, compared with 28.8% of AMGs. “Lack of jobs/practice opportunities that meet visa status requirements” was one of the top reasons. Forty-four percent of IMGs reported changing their plans because of limited nephrology job opportunities. In contrast, there are abundant jobs around the country in hospital medicine, and eligible IMGs are attracted to hospital medicine because of the ease of finding a job in a desired location, the higher pay, and flexible schedules. Therefore, we are seeing a trend whereby IMG nephrologists are choosing to work as hospitalists. For employers, this backlog brings a perennial source of expense, paperwork, and the uncertainty of sponsoring a visa.
There is also a growing emphasis on innovation in nephrology. What if a visa-dependent nephrologist comes up with an innovative idea for a product, service, or business venture? Under the immigration laws, nephrologists with H1B visas are permitted to work only for their sponsoring employers, which means that working toward realizing an innovative idea becomes unpaid voluntary service.
These are some of the ways the green card backlog is adversely affecting the present and future of nephrology in the United States. Multiple potential legislative solutions have been around for many years. We can hope that legislation to clear these backlogs will provide a much-needed boost to our beloved specialty. But until then, we keep calm and carry on.