Protecting the Careers of International Medical Graduates on a Visa: What Can Be Done?

Recruitment into fellowship

Program directors and recruitment committees should be realistic and transparent during the fellowship interview process. IMGs envisioning themselves as physician scientists have a steep mountain to climb, and many applicants may not have fully considered nor been aware of the implications of choosing to pursue such a pathway. Society or foundation research grants and bridge funding (division clinical funds or extramural non-federal funds) will be required to support research careers until permanent residency or citizenship criteria can be obtained and US National Institutes of Health (NIH) funding mechanisms can be unlocked. Programs should clearly state their capacity to support such applicants and be transparent with applicants seeking such research pathways. J-1 applicants are obligated to serve a 3-year, full-time (1.0 full-time equivalent [FTE], at least 40 hours/week) clinical commitment in an underserved area (also known as a J-1 waiver) before they can even apply for permanent visas and hence, do not qualify for protected research time. Special efforts must be taken to preserve the research interests of such individuals (3).

Awareness of the immigration process

Division chiefs, clinical directors, and practice leaders should take steps to understand and learn the basics of physician immigration, such as the following:

• Waiver of home requirement (only for J-1): Also known as a J-1 waiver, this process has strict timelines and multiple steps that vary by state. Leaders should understand the legal steps in the waiver process and identify waiver catchment areas—practices and service areas that qualify as waiver sites within their practice base (4).

• Pathway to permanent immigration (J-1 and H1-B): Obtaining a green card through employment-based (EB) categories. There are two main EB categories: EB-1 requires an outstanding and exceptional ability that comes with stringent criteria, and EB-2, for which all physicians qualify, has become an impossible path to permanent residency for individuals from India (wait time >150 years) and China (wait time 5–8 years) since green card allotment is based on country of birth (5). Understanding the paperwork and basic criteria will enable nephrology leaders to provide valuable guidance to their trainees as they move forward in their careers.

Workgroup for formulation of guidelines on visa hires

There is concern over new graduates signing contracts at potentially malignant and predatory practices. Because nephrologists who are IMGs are entirely dependent on visa sponsorship through the practice, they are particularly susceptible to mistreatment. This could include a variety of situations that are averse to growth and development of a successful career.

• Practice oriented: excessive work hours, higher frequency of calls

• Career oriented: impediments to attaining partnerships, compensation increases not offered despite meeting requirements

• Immigration oriented: delay or non-processing of visa and immigration paperwork either from maleficence or lack of understanding of processes

J-1 trainees, whose initial waiver contract is for 3 years, have binding clauses that make it nearly impossible to switch or change jobs. Trainees with any visa waiting for a green card after submission of immigration paperwork face similar hurdles and as such, are vulnerable to practices looking to profit from their labor.

Although there are no resources or legal ways for our national societies to hold nephrology groups accountable for misleading practices, they can formulate guidelines on hiring an immigrant physician and recommend that practices advertise to trainees on visas that they follow appropriate procedures. Such guidelines shall broadly include the following:

• Prompt processing for a visa waiver (if applicable) or work visa, as well as application for permanent visas, including covering legal fees

• Specifying work hours or a schedule in the contract, compensation in line with median salary within the group, and bonuses (if applicable) in line with others in a similar role within the practice

• Offering partnerships, compensation hikes, and opportunity for joint ventures through the usual schedule within the practice

National database

To research and maintain standards, national societies need to establish and maintain a database of trainees and their practice locations in the first 5 years of practice and conduct yearly surveys to assess whether the aforementioned obligations were met by the practices that hired them. Identifying systemic problems will help our leaders form clear targets for improvement and focus resources on high priority issues.

Immigration advocacy

The ASN Policy and Advocacy Committee and other societies in nephrology play leading roles in advocating for legislation that improves the care of kidney patients. In addition, increased representation of IMGs on the ASN Policy and Advocacy Committee and advocation for bills that ease immigration rules and the transition of physicians from immigrants to permanent residents, in concert with other organizations (such as the American Medical Association) that play a pivotal role in advocating for immigration reform, are warranted (6).