As a specialty, nephrology is heavily dependent on international medical graduates (IMGs). According to the Association of American Medical Colleges (AAMC) (1), 65% of nephrology fellows in 2019 were IMGs, the highest of any major internal medicine specialty. This has now led to more than one-half of the active workforce being graduates of international medical schools (51%). Although the exact numbers of IMGs on a visa and the proportion of J-1s and H1-Bs are unknown, it is well recognized by local and national leaders that providing viable and satisfying solutions for entry into the workforce for a nephrology fellow on a visa has never been more crucial. According to a 2019 ASN survey (2), nearly 50% of IMG respondents reported having difficulty finding a satisfactory position, with major barriers being location of practice, adequate compensation, and visa requirements. These unfortunate numbers reflect the arduous path that a fully trained graduate on a J-1 visa embarks on while trying to commence a career in the United States.
Upon graduation, a J-1 trainee is mandated to go back to his or her home country for 2 years or obtain a waiver to stay in the United States; this can be obtained by working in an underserved area or filing a claim for persecution or hardship (3). In the current immigration climate, it is vital that fellowship program directors and division chiefs understand and have utmost clarity in the hiring process, so they can provide their trainees with direct and practical guidance, thereby lessening the trainees’ anxiety and distress. If you are a program director, division chief, or mentor, the following information is what you need to know (Figure 1).
STEP 1: Know your hospital or practice location.
Enter your hospital address on the Health Resources & Services Administration's website (https://data.hrsa.gov/tools/shortage-area/by-address), or search Health Professional Shortage Area (HPSA) by address to find this tool.
Your entering the address provides two pieces of information: 1) whether the location lies in a medically underserved area (MUA) or HPSA (noted as “MUA/P” [MUA or Population] and “Primary Care HPSA”; dental and mental health HPSAs do not qualify) and 2) the HPSA score (1−25) for the location; the higher the score, the higher the priority.
Only one of the above (MUA or HPSA) is required for the location to be eligible for a J-1 waiver, and the county must be highlighted as green on the map. However, if the county in which the practice is located appears red, then it is not a MUA or HPSA location. This doesn't mean the end of the road, however, as there are two options to explore.
Is there a different practice location for the division or practice that can serve as the primary practice location for the new hire? These could be outpatient practices, smaller network hospitals, dialysis units, interventional suites, or a combination of the above. Check if these locations are green on the map.
FLEX spots: Most states allow eligibility if the practice in a “red” location can show that the new hire will take care of underserved patients from a “green” location. However, note that FLEX applicants are the lowest priority for most states.
STEP 2: Know your state.
Although it is impossible to keep up with requirements of every state, it is simple for employers to understand their home state. The easiest and most efficient way to accomplish this is to have a conversation with an immigration lawyer or the liaison at the international office. It is important to know the chances of approval for a particular practice and state. Your spending months on paperwork in a state where chances of approval for a particular specialty or location are low would not be prudent.
There are a few government agencies that sponsor visa waivers. Some, such as the Appalachian Regional Commission (ARC) or US Department of Health and Human Services (HHS), do not accept specialties like nephrology, and others, such as through the Veterans Affairs (VA) administration, are extremely hard to get or have limited spots. However, if the employer is located in eligible parts of 8 states (MO, IL, KY, TN, AR, LA, MS, and AL), the Delta Regional Authority (DRA) may be a potential sponsor. But, by far, the most common pathway is the Conrad 30, a federal program that allows each state 30 such positions. Therein lies the problem, however: each state, regardless of size, population, or need, gets 30 positions. Texas and New York get 30, as do North Dakota and Wyoming.
Approval process
The following are some issues that play into approval chances:
Preference for primary care specialties (internal/family medicine, Ob-Gyn, pediatrics, psychiatry): some states (e.g., NJ, NY, CA, etc.) only accept or allot most of their spots for primary care.
Has the state recently granted FLEX waivers? If yes, how many? The maximum is 10 per state, but most states accept far fewer due to demand and ability to fill with non-FLEX (HPSA/MUA) applications.
Allocation system: states use different methods to pick applicants, such as:
first-come, first-served basis (e.g., CO, AR, ID, etc.)
primary care first followed by priority ranking of specialists by HPSA score or other rules (most common)
lottery system (e.g., FL, CT)
locally trained applicants or applicants with language skills preferred in some states
limits per employer in some states; thus, employers asked to prioritize order of applications
The second part of approval is paperwork, which includes the following:
Trainees cannot apply to more than one state at a time. So it is important to understand state application deadlines (typically September/October) and approval/rejection deadlines in primary states and also in backup states. Backups are typically in states with late deadlines or those that never fill and accept rolling applications throughout the year.
Paperwork may appear daunting, but requirements are straightforward. Quality legal representation is vital and typically costs around $5000−$10,000. Paperwork is a mere hindrance as long as planned in advance:
Some states require full medical licenses to be eligible to apply.
Most states require displaying recruitment efforts for 6 months.
Some states require letters of support from community physicians or organizations.
Some states have specific contract clauses, such as no non-competes.
Once an application is picked by the state's Department of Health, the subsequent progress through the US Department of State (DOS) and US Citizenship and Immigration Services (USCIS) is uncomplicated. An H1-B visa is granted at the end of the process, and the employee is bound to the state and the practice for 3 years, a time during which a green card cannot be obtained. Some states (e.g., AL and GA) have heavy liquidation clauses of $250,000 if an employee decides to terminate his or her contract. Also, a job switch is near impossible during the 3 years and requires the employee to demonstrate extenuating circumstances and even then, only allows a switch to another location within the same state that falls under the HPSA/MUA designation.
Under such trying circumstances, it is essential for our leaders to understand the granularities of the process. Failure to find solutions comes at a great cost, with many specialty-trained physicians opting to work in hospital medicine or primary care when they are unable to find a reasonable waiver position or when their application is rejected. Regardless of whether trainees are hired as faculty at their teaching hospital or at private community practices, leadership input will be valuable to trainees in helping to find positions that provide career paths in nephrology that are desirable, fulfilling, and sustainable in the long term.
References
- 1.↑
Association of American Medical Colleges (AAMC). Physician Specialty Data Report. Accessed November 11, 2021. https://www.aamc.org/data-reports/workforce/report/physician-specialty-data-report
- 2.↑
Sozio SM, et al. 2019 Nephrology Fellow Survey Results and Insights. ASN Alliance for Kidney Health, 2019. Accessed November 11, 2021. https://www.asn-online.org/education/training/workforce/Nephrology_Fellow_Survey_Report_2019.pdf
- 3.↑
Neyra JA, et al. International medical graduates in nephrology: A guide for trainees and programs. Adv Chronic Kidney Dis 2020; 27:297–304.e1. doi: 10.1053/j.ackd.2020.05.003