CHESTThought Leader BlogTraining on a Visa

Training on a Visa

By: Enambir Josan, MD

Roughly 30,000 medical graduates match into various residency programs in the United States each year. Approximately 7,000 of these are graduates of non-US medical schools: International Medical Graduates (IMGs), who fill a significant vacancy in US-based residency positions each year. About half of these are foreign nationals who require a visa sponsorship to pursue this training. In fact, a quarter of US physicians are IMGs, and a majority of them work in primary care or medical specialties. As an IMG, I feel incredibly fortunate and content with the training I have received, and I want to share some of the unique experiences of training on a visa.

The first step is the hardest: In contrast to the 94% of American Medical Graduates (AMGs) who matched in 2020, only about 60% of IMGs did. The United States Medical Licensing Examination (USMLE), clinical rotations, and “The Match” are expensive rituals and could be worth a year’s savings for most IMGs. The rewards are obviously worth it, since the residency is an enlightening experience. Next comes relocating to the US, which is a fascinating journey full of both joy and apprehension. I visited a city for a single day for a residency interview, and it ultimately became my home for the next 3 years. Most IMGs don’t have a family in the US and have to navigate the nuances of “adulthood,” such as finances or taxes, with the help of their colleagues. To some extent, it was like being reborn into my family of co-residents.

Immigration 101: A foreign national will require a valid visa to cross the US border and an authorization to legally work here. A visa can only be stamped by the American Embassy in a country other than the US. While I could work/reside with an expired visa, I’d still require the valid authorization. The two common visas available for Graduate Medical Education (GME) training are the J1 ( “exchange visitor”) and the H1 ( “temporary worker”). The J1 visa program facilitates the exchange of knowledge when the IMG returns to their home country post-residency. It is issued on a yearly basis regardless of total training duration with a limit of 7 years. It is the predominant visa sponsored for residency and almost exclusively the only visa sponsored for fellowship training. H1, on the other hand, is issued for 1-3 years and facilitates easier recruitment post-residency whilst providing an easier path to immigration.

Fact #1: Subspecialty matching is exceedingly competitive for IMGs. A trainee on J1 has a better chance of matching into subspecialty training compared with H1 due to the ease of sponsorship. However, they only get one shot because an unmatched J1 trainee can’t reside or work in the US unless they pursue a long and complicated process of meeting J1 waiver requirements. This entails signing up for an eligible position a year ahead of time and a three-year contract, amongst other things. If I hadn’t matched into fellowship in my first attempt, I would have had to leave the US without pursuing my dream to specialize in pulmonary and critical care medicine, followed by interventional pulmonology. Luckily, I succeeded both times and will be able to follow my aspiration without an interruption. H1 trainees, on the other hand, have limited programs for subspecialty training and therefore have a harder time pursuing it. On the bright side, they can work after residency with proper authorization while reattempting to match in subspecialty training.

Fact # 2: Traveling is cumbersome. Most US GME programs allow 3-4 weeks of vacation time each year. Since the J1 and most training H1 visas are issued for only a year at a time, an IMG with an expired visa will need to reacquire it prior to re-entering the US. So if I intend to visit India this year, I will need to go to a US embassy as soon as I arrive for a 2-day interview and set aside a minimum of 2 weeks while awaiting my visa to be reissued. The whole process is necessary for immigration refinement, but it is not as charming when you have to spend your vacation time navigating it. Even before the pandemic, instances of visa denials mid-training weren’t uncommon for both the IMG and their family. This often leaves the trainee having to weigh the risk of travel with the risk of jeopardizing their training. Travel bans on some countries prevented one of my colleagues (amongst many others) from being with her mother during her last breath. Amidst the pandemic, all IMGs were deterred from traveling outside the country because their re-entry into the US “could not be guaranteed" by the Educational Commission for Foreign Medical Graduates (ECFMG). My biggest fear this year wasn’t surviving the pandemic; it was potentially having to choose between staying in the US or taking a risk of traveling to visit my family if they got sick, possibly jeopardizing my training.

While training on a visa has its nuances, it does provide an incredibly rewarding opportunity to IMGs. There is really no limit to what you can achieve in a system that endorses equality and diversification regardless of religion, race, or nationality. That’s what makes America great.

Enambir Josan, MD
Enambir Josan, MD, is the Chief Fellow for the Division of Pulmonary Disease, Critical Care and Sleep Medicine at the Case Western Reserve University/MetroHealth program in Cleveland, Ohio. He is a member of the Trainee Work Group at CHEST. His clinical interests include interventional pulmonology, lung cancer, and medical critical care.