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International Medical Graduates
Author: Allison McCarthy, MBA
While this article was originally written and distributed in July 2007, the author updated the content in March 2009 to reflect the increasingly competitive recruitment environment.
Recent dialogue in the medical and planning arena centers on the potential shortage of physicians. Some argue that the United States does not train enough physicians and that certain specialties and under-served locations face significant issues in the not so distant future. Enter the International Medical Graduate — a person who obtains his/her medical school education outside of the United States and Canada. Known as IMGs or FMGs, there is a growing number of them seeking employment and account for almost one quarter of the nation's active physicians.
| Internal Medicine | 36% | 55,467 |
| Anesthesiology | 29% | 11,757 |
| Psychiatry | 31.4% | 13,080 |
| Pediatrics | 28% | 20,180 |
| Family Medicine | 17.8% | 21,669 |
| Obstetrics/Gynecology | 17.8% | 7,589 |
| Radiology | 18.8% | 1,530 |
| General Surgery | 20% | 7,970 |
Source: Physician Characteristics and Distribution in the U.S. 2007 edition; AMA, Chicago, IL (Data excludes residents and students)
While recruiting IMGs can be perceived as arduous for a hospital, if you are in a difficult to recruit area, have a community with ethnic and cultural diversity for which you need to address their health care needs or you are recruiting in a specialty where there is high demand and low supply then this avenue may be worth exploring for your organization. If your organization's strategy is to recruit IMGs to round out your medical staff complement, you need to be aware of the requirements necessary to employ or sponsor an IMG physician.
Required for Practicing Medicine in the United States
If choosing to practice medicine in the United States, an IMG has five basic steps to employ:
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Have a degree from a medical school outside the U.S. or Canada.
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Obtain a certificate from the Educational Commission for Foreign Medical Graduates (ECFMG). This certification addresses the issues of varying standards in medical schools outside of the U.S. and Canada by assessing the level of preparedness an IMG has for participating in a residency program through a series of exams. Additionally, credential requirements include providing documentation of medical education credentials. The process for certification and the required retraining are described at www.ecfmg.org.
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Pass the United States' Medical Exam — Parts 1 and 2 (and possibly 3 depending on the Visa).
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Pass the ECFMG — Administered English language exam.
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Complete a U.S. based medical residency program regardless of training received outside of the U.S./Canada. Many medical graduates are placed in residency programs through the National Residency Match Program, www.nrmp.org.
An IMG can also practice in the U.S. if one of the following circumstances apply:
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The Fifth Pathway Program — an IMG has completed undergraduate college in the U.S. and completed all their formal medical school requirements except the internship and/or social service obligation outside the U.S. or Canada.
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Licensure Requirement Exemptions for Eminent Physicians and Medical School Faculty A select few IMGs may be eligible for special consideration if they are "eminent" physicians or will be serving on the faculty of a medical school.
There are two types of visas that an IMG will need to practice in the United States:
J-1 Visa — Exchange Visitor Status
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This Visa is provided to foreign nationals with permission to participate in US educational, teaching, and training, research, or other international exchange programs recognized and approved by the Department of State. They must be sponsored before entering the United States and are restricted to the specific program for which the status was granted.
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It is only necessary to take parts 1 and 2 of the U.S. Medical Exam with this type of Visa.
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Must return to their home country for two years after training but before they can practice medicine unless they obtain a J waiver (see below).
J WAIVERS
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Require sponsorship from an IGA (interested government agency) like the Department of Health and Human Services. And then the individual will only obtain this type of sponsorship if working in a federally designated health provider shortage location or a medically underserved area (MUA). There are some additional circumstances for granting a J Waiver that have to do with family hardship or personal vulnerability for returning to the home country.
To determine if your organization is located within a health provider shortage area, check http://bhpr.hrsa.gov/shortage/hpsacrit.htm. This web site will show current designated areas and those that have a potential for being designated.
If the organization is not in an MUA, going through the process of obtaining the waiver is considered to be quite difficult.
If the organization is in a MUA, the process is lengthy, and would include completing an application, waiting for the application to be approved and waiver to be granted, and then having the physician apply for a H1B Visa, which requires additional time. It is not unusual for the process of getting the waiver to take 6—8 months and cost several thousand dollars.
H-1B — Temporary Worker Status
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Must take all three parts of the U.S. Medical Exam with this Visa.
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Residency program acts as employer and serves as the sponsor for this Visa.
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Once residency is completed, a new employer can offer employment sponsorship.
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Not required to be in a location that has a shortage of physicians to obtain employment sponsorship.
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While working with H-1B status, can initiate the process for obtaining a Green Card for permanent permission to work in the U.S.
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H-1B is employer specific or residency specific (a firm offer of employment is required) for an initial period of three years with the possibility of renewal for an additional three years. Extensions beyond the six years may be granted in one year increments. If there is a change with the residency program or the employer, the IMG must obtain a new H-1B. The process can take 60 — 90 days to process the H-1B petition. New employment can begin upon filing of the application.
Green Card
An IMG may obtain a green card if he/she has a permanent employment opportunity in the United States, or if the employer wants to sponsor an IMG's residency based on permanent employment. This is a multi-step and often elongated process. Specific information can be obtained by reviewing the web site: http://uscis.gov/graphics/services/residency/physwaiver.htm
Additionally obtaining a green card:
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Requires labor certification — a U.S. employer will need to show evidence that a U.S. citizen could not be hired for the position. This requirement is generally satisfied by providing documentation of advertising in national journals for the physician position along with responses and attempts at hiring.
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Must have a national interest waiver again provided by the employer demonstrating physician need and the difficulty in recruiting that particular specialty.
Conclusion
Recruiting IMGs may be a longer term plan for your organization to fill high demand medical specialties. Knowing what is required for the physician to practice in the United States is important. With knowledge of how the process works, a recruiter can help the IMG with information and can help the organization understand the time-frames, resources and requirements involved. Obtaining good legal counsel to help navigate the process is a must. And ensuring that your IMG candidate is serious about your opportunity and not just the assistance in obtaining a waiver or H-1B status is also very important.