According to 2009 National Resident Matching Program (NRMP) statistics, international medical graduates (IMGs) comprise more than half—52 percent—of the fellowship applicants matching in nephrology. Here I describe my personal experiences as an IMG on an H1-B visa applying for a nephrology fellowship. I have also applied for fellowships through the couples match program as my wife is pursuing fellowship training in infectious diseases. Although I present my own personal experiences throughout the match process, it is important to keep in mind that these experiences are not in any way unique. Most of my colleagues have encountered many of the same obstacles. Based on my experiences, I suggest mechanisms for improving future nephrology match experiences for other IMGs.
My passion for nephrology was always discouraged by my colleagues. It is commonly believed that acceptance into a nephrology fellowship on an H1-B visa is extremely difficult. Senior residents who had applied for nephrology fellowships in previous years told me to secure my visa status first and then apply for fellowship. Unfortunately, there is no reliable official source of information on this issue.
As an intern, I participated in the American Society of Nephrology (ASN) Resident Program. ASN provides travel support grants to internal medicine residents from across the United States who are interested in nephrology to attend the ASN Annual Meeting. The resident program includes a reception for residents and fellowship program directors. At this reception I had the opportunity to meet nephrology program directors from all regions of the country. Through this event I learned that only a few programs sponsor H1-B visa-holding fellows. In addition, fellows on H1-B visas who are interested in pursuing additional research training as part of fellowship will likely have significant issues with funding while on this visa and may not be afforded opportunities for additional research training. The ASN resident program provided me with the most important information on available fellowship opportunities. Efforts to publicize and promote this program would be helpful to IMG applicants for nephrology fellowships.
In early October 2009, I started sending emails to fellowship programs asking if they would sponsor an H1-B visa applicant. I sent emails to 141 programs listed on the Fellowship and Residency Electronic Interactive Database Access (FRIEDA). By November, I received replies from almost 85 programs—only 35 sponsored fellows on H1-B visas. I applied to all of these programs in early December. A few weeks after applying, I received rejections from three programs because they decided not to sponsor H1-B exist visa applicants that year.
One program later denied me an interview because “they only accept domestic candidates.” Later in the interview process, a few more programs that had previously reported sponsorship of H1-B visa holders sent me rejection letters because of a reversal in their visa acceptance policy. Confusion could be prevented if programs would simply and clearly mention their policy toward fellowship opportunities for H1-B visa holders on FRIEDA or their own websites.
In early January 2010, I received my first interview call and ultimately had 15 interviews by the end of March. To my surprise, although I had clearly mentioned on my electronic application that I was applying for a nephrology fellowship through the couples match in which my wife was applying for an infectious disease fellowship, not a single nephrology program coordinated with the infectious disease programs to which my wife had applied. I sent emails to the various infectious disease divisions myself in an attempt to coordinate interview schedules with limited success.
Interview season for infectious disease fellowship positions started somewhat later than nephrology, but the infectious disease program directors coordinated more proactively with nephrology divisions for our interviews. In despair, with fears of not matching at the same institution, my wife and I began making plans for hospitalist positions or possibly even living apart for our fellowship years. Since nephrology is new to the match process, it may be that program directors have limited knowledge about the couples match. Perhaps if the NRMP educated training programs about the couples match process, better coordination between specialties could be achieved and couples would be invited for interviews as a couple, rather than as individuals. Residency training programs have operated with a couples match for years. There is no reason fellowship programs cannot do the same.
Throughout the interview process and in speaking with peers, I also noticed what may be a geographical bias in interviewing fellowship candidates. For example, programs from the East Coast tended to interview only candidates with East Coast addresses on their electronic application. This presumptive bias to select fellows in part based on geographic residence might be reasonable for U.S. graduates but does not hold true for most of the IMGs. Most IMGs do not have families in the United States and their choice of fellowship programs is already limited by visa issues. Thus, many IMGs do not have geographic constraints for fellowship. During the interview, I sometimes found it very difficult to convince the program director that I did not have a geographical preference for fellowship training. In my opinion, programs need to be mindful of this issue and realize IMGs may be quite willing to move long distances for fellowship training.
I started interviewing in early February and would like to highlight a few of my interview experiences in the hope that my experience may lead to improvements in the process, especially for IMGs. Generally speaking, the expense of one interview is $350 to $400 or even higher. I personally took each interview very seriously. I went to a program in the Midwest through a snowstorm and, to my disappointment, the program director had not even reviewed my application. He glanced through my application during my interview and remarked, “Oh, I did not know that you are on an H1-B visa.” My time and the expense of this interview could have been saved since that program was not interested in candidates with H1-B visas.
Some training programs seemed to have a good interview philosophy and process; these program directors seemed genuinely interested and had actually reviewed my entire application. Clearly, interviewers have different styles, but displaying an interest in the fellowship candidates and candidly offering opinions on the strengths and weaknesses of one’s training programs are valuable to applicants. Having other fellows available to speak with applicants on the interview day is helpful. Fellow satisfaction was an important consideration for me in making my rank order list.
There are multiple pressures on the candidate during the whole interviewing and matching process. One pressure is to show the program that you are genuinely interested. Most programs seem to want to hear that you are going to rank them first, which obviously is not possible. Clearly both the program and the applicant would like to know each other’s probable ranking, but the match was designed to eliminate this issue from the interviewing process. There should be enough respect among the parties to avoid asking this question.
Many programs asked me to name other programs in which I interviewed. This violates NRMP rules. Although it is understandable (an assessment of geographic preference, clinical or research predilection, etc., may be gained by the answer to this question), interviewers should be educated about the need to avoid this inquiry. Some program directors clearly told me to “keep in touch, as this really affects our ranking.” However, no specific instruction about how or when to “keep in touch” was provided. One of the program directors spoke to the candidates at the end of the interview and told us not to feel pressured about sending follow-up “thank you” before submission of the NRMP rank list because this would not affect their ranking of us. This small gesture was deeply appreciated by all the candidates at the interview.
My story has a happy ending—my wife and I matched together. Because nephrology is new in the match, multiple opportunities exist for improving the process for programs and for candidates. Programs should clearly state their policy on visa sponsorship. Couples should be considered together during the application process. Interviewing should be a pleasant, informative, and pressure-free experience both for the candidates and the programs. Implementing these simple guidelines will create a positive impression of fellowship programs and provide candidates with a sense of fairness and satisfaction throughout the match process.