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Any foreign medical doctor who wants to practice medicine in the US has to meet the following requirements to obtain ECFMG (Educational Commission for Foreign Medical Graduates) certification:

  • Certifying that the FMG obtained a degree listed on the World Directory of Medical Schools
  • Complete missing education requirements
  • Medical Science Requirements – You must pass both the USMLE Step 1 and USMLE Step 2 CK (Clinical Knowledge)
  • Clinical Skills Requirement – To practice medicine in the US after graduating from med school in another country, you must also pass the USMLE Step 2 CS (Clinical Skills)
  • Going through a residency program
  • Obtaining final ECFMG certification

Starting all over

Now that you have achieved your final ECFMG certification, there is no guarantee that you can be employed in the US. While many FMGs have years of experience in treating patients, many become disillusioned about actually practicing medicine in the US.

The good news is that by 2025, the American Association of Medical Colleges projects primary care shortfalls ranging from 12,500 to 31,100 doctors, and shortages of non-primary care doctors between 28,200 and 63,700.

Foreign-trained doctors are critical to addressing these shortages, accounting for important shares of primary-care physicians in the United States. Nearly a third (31.8%) of all physicians specializing in family medicine, internal medicine, and pediatrics—three specialties associated with primary healthcare—are foreign-trained.

Immigration: What are my visa options as an FMG?

H-1B Visas

The H-1B Visa is the most in-demand option for doctors immigrating to the US. This visa is used by many professionals in the medical industry. In order to get approved for this visa, you will need to have an existing job offer for full-time employment with a US employer such as a hospital, university, clinic, doctor’s office, or assisted living community.

O-1 Visas

To be approved for an O-1 visa you will need to demonstrate through awards, publications, or other evidence that you have extraordinary accomplishments in the medical field. The position which you are going to work in once you arrive must require someone of well-above-average skills and experience.

TN Visa

If you are a doctor from either Canada or Mexico, then you may qualify for the TN visa. This visa is for physicians who are going to work in the US as either teaching or research doctors. While you are able to work with patients directly, the total amount of time providing patient care should make up less than 10% of your total duties.

J-1 Visa

The J-1 Visa is a great option for foreign-born doctors because it allows physicians to attend residency and fellowship programs in the US. The J-1 Visa requires a successful passage of the ECFMG examination and acceptance into the training program.

E-2 Visas

The E-2 Visa is an investor visa but can sometimes be used for doctors. If you are a doctor/physician looking to invest in a medical business in the US and you’re coming from a treaty country, then you may qualify for the E-2 Visa. For example, if you are looking to come to the US to open a medical office this would qualify for an E-2

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Highlights of the most sought-after visas

Placing J-1 physicians and obtaining J-1 waivers using an IGA (an interested government agency)

  • Physicians must work in H-1B status for a minimum of three years.
  • Physicians must be an employee – not independent contractors or sponsoring employers.
  • Employers and physicians must submit periodic reports to state or federal health agencies (some states).
  • Physicians cannot change employer unless extenuating circumstances (e.g., termination by employer) – personal reasons exceptionally valid for a change of employer.
  • Physicians can only become permanent residents once the waiver service is completed.
  • J-1 obligations
    • Employer and Physician apply to IGA.
    • IGA issues recommendations to the Department of State (DOS) (4-6 weeks)
    • DOS issues recommendation to USCIS (3-4 months)
    • USCIS issues final waiver approval I-612 (1-2 months)
    • H-1B petition filed and approved (15 days or approx. 4 months)
  • START-Strategic planning for J-1
    • Start – job search one year before completion of residency or fellowship.
    • Target – employers in HPSA/MUA or Flex areas
    • Agreement by early Fall of 3rd year of residency or final year of fellowship
    • Recruitment – document current recruitment efforts by the employer
    • Timely – file waiver application at the first available date

Placing H-1B physicians H-1B is the most common program for IMGs to work in the United States.

  • First-time H-1B Applicants or H-1B employees previously CAP-exempt.
  • Quota – 85,000 H-1B visas per fiscal year (Oct. 1 – Sept 30)
    • 65,000 for persons with BS degrees
    • 20,000 for persons with US Master’s degrees or higher
  • Avoiding the H-1B Cap
    • CAP-Exempt Beneficiaries (Employees)
      • Physicians who are beneficiaries of J-1 IGA waivers only (does not include hardship waivers or persecution waivers)
    • CAP-Exempt Petitioners (Employers)
      • Universities & non-profit employers affiliated with higher education organizations
      • Government research organizations & non-profit petitioners affiliated with government research institutions
      • For-profit employers place physicians to work (at least 50% of the time) at universities or non-profit employers affiliated with higher education organizations.
    • Concurrent H-1B Employment
      • J-1 or H-1B Physicians
      • Part-time employment
      • Term – duration of primary H-1B visa max
    • IMG physicians can work as independent contractors (1099) – locum tenens
      • Form a corporation or limited liability company (LLC).
      • USCIS “… evidence that there is a separate Board of Directors which has the ability to hire, fire, pay, supervise or otherwise control the beneficiary’s employment, the petitioner may be able to establish an employer-employee relationship with the beneficiary.”
  • Strategic Plan for H-1B Recruiters
    • Start job search immediately after 2nd year of residency or one year before completion of fellowship (prefer cap-exempt employers)
    • Finalize employment by early Fall of 3rd year of residency or final year of fellowship
    • If competing for CAPsubject H-1B – have a contract in place by February so that H-1B registration can be completed in March – if selected petition can be filed starting April 1
    • Apply early for a medical license
    • Refer physician or employer to immigration attorney early in the process

Placing O-1 Physicians

  • The physician has “risen to the top of the field.”
  • Specific employer
  • Term- one to three years. Indefinite extensions
  • Physicians may change employment so long as the new employer files a new O-1 petition.
  • A j-1 waiver is not required so can be a “stop-gap” visa when a waiver is not available.

Placing physicians with pending green cards: two paths to legal permanent residence (LPR) or Green Card

  • Employment
    • Labor Certification
      • Employer sponsorship is required.
      • The employer must pay part of the attorney fee and other costs
      • Portability if the same or similar occupation
    • National Interest Waiver
      • Self-sponsored
      • Five years of service in HPSA or MUA
      • Self-employment permitted
  • Employment Authorization Document (EAD)
    • EAD Issued with pending green card application through family, employment, (diversity lottery, asylum, refugee, etc.)
    • Limited period of authorization – must renew before the expiration
    • Can work for any employer
    • If the green card application is denied, no longer authorized to work

In summary, immigration to the US is a complex process. It is vital to have an immigration professional on your side.

Contract Diagnostics is not a law firm nor an immigration firm, but has helped nearly 1,000 physicians with Visas understand and negotiate their employment contracts to ensure fair pay and risk mitigation. Contact them for more information on how they can help you throughout your career journey.

About the Author

Dr. Drew Sutton, MD, has walked the long road of a successful medical career, amassing invaluable insights and expertise. With a wealth of knowledge derived from his time in the trenches, he understands the myriad challenges and opportunities that come with physician contracts and compensation. Dr. Sutton is not just sharing theoretical knowledge; he imparts lessons learned from his own hands-on experience in the medical profession. Dr. Sutton has been where you are, and he’s navigated the path to where you want to be.

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