The nephrology subspecialty, both at the fellow and practitioner level, has a greater percentage of international medical graduates (IMGs) than any other internal medicine subspecialty with the exception of geriatrics. As such, the contributions of IMGs to our field are tremendously important and we must work to continue to make nephrology an attractive career choice for them.
There are a number of challenges relating specifically to potential IMG fellows. Since J-1 and H1-B visa holders are not eligible for funding through the NIH, their options are substantially limited if they are interested in research training. Owing to limitations imposed by many states, obtaining waivers for H1-B holders is difficult if not impossible for many programs. Programs have a wide variety of approaches to J-1 and H1-B visa holders, so getting specific information from individual programs is required. To facilitate this, ASN could develop a list of programs that accept H1-B and J-1 visa holders. The ASN residents program is also a valuable source of information for all prospective nephrology fellows. This program is advertised on the ASN website and through direct communication with all nephrology training program directors (TPDs). The nephrology TPD contacts the internal medicine or pediatric TPD in order to advertise the residents program. ASN is aware of the challenges in recruiting nephrologists and is actively working on long-term plans to increase the visibility and attractiveness of our subspecialty to undergraduates, medical students, and residents.
Dr. Saeed did an excellent job of identifying appropriate programs and still ran into difficulties on the interview trail. Many of the problems he encountered are readily avoidable with a little extra attention to detail by the TPD. Clearly, TPDs must familiarize themselves with local policies toward visa holders and be very careful about which visa holders they select to interview. Posting an institution’s policies toward visa holders on its website is an excellent idea—it would help prospective fellows and would also help remind TPDs of the importance of this issue.
Other issues that Dr. Saeed raises apply to all applicants, regardless of nationality. First, the couples match is well known to nephrology TPDs, having been part of residency program recruitment for many years. While it does complicate planning, it is readily addressable with a little extra time spent in coordinating interviews. This is not a National Registry Matching Program (NRMP) issue and simply requires TPDs to alert the person doing the interview scheduling to discuss coordination of interviews with the applicant.
Secondly, I question the geographical bias of training programs. With the exception of some programs that predominantly take applicants within the immediate area, TPDs are generally looking for the best applicants, regardless of their location. I would be very surprised if an excellent candidate was not interviewed because of his or her location.
A third issue relates to adhering to NRMP guidelines. It is unequivocally stated by the NRMP that it is not permissible to ask applicants about ranking preferences or other interviews. Such infractions can be reported to the NRMP, and programs can risk being excluded from the match.
Nephrology is relatively new to the Electronic Registry Application Service and the match and, while having made substantial strides, still has adjustments to make. Standards for conducting interviews have been established by the NRMP, and all TPDs should be closely adhere to them. ERAS provides more applicants per program, and more applications per applicant (particularly with regard to IMGs), than in the pre-ERAS era. Programs need to be aware of these application trends and work to facilitate the process of matching the right applicant with the right program with as little stress to either as possible.