Navigating a Career in Infectious Diseases: A Guide for International Medical Graduates

Paul Sax: [00:00:14] Hi everyone. This is Paul Sax. I'm editor in chief of Clinical Infectious Diseases. And welcome to the Let's Talk ID podcast. Well, as everyone knows, the ID workforce in the United States relies heavily on the talents of international medical graduates who come to us from all over the world, broadening our insights and perspectives and adding wonderful diversity to our faculty and fellows. So today we're going to talk about how we can support these trainees, especially during fellowship and in the early faculty period. I'm joined by two experts in this area, Dr. Vidya Sundareshan and Dr. Alfredo Mena Lora. Dr. Sundareshan is professor in chief of infectious diseases and ID fellowship program director at Southern Illinois University School of Medicine in Springfield, Illinois. And Dr. Mena Lora is assistant professor and program director for ID fellowship, University of Illinois, Chicago. Welcome, Vidya and Alfredo.

Vidya Sundareshan: [00:01:07] Thank you so much for having me. Excited to be here.

Alfredo Mena Lora: [00:01:11] Same here. Very excited to join you.

Paul Sax: [00:01:12] Well, you know, it's always nice to hear people tell their stories. And what is your story? With a focus on how you chose medicine in general and ID in particular. And Alfredo, why don't you start us off?

Alfredo Mena Lora: [00:01:24] I absolutely love medicine and I love ID. I think to make my long story short, it was mentorship. I loved everything about medicine, and ID encompasses all organs and all body parts and things outside of the bedside too. But it was a mentorship experience in Haiti under Dr. Bill Pape at the Gheskio clinic, where they do amazing work. I fell in love with ID because it touches so many different societal issues, so many different organs, so many different body parts, and we can have a big impact in a patient and in society.

Paul Sax: [00:01:53] Yeah, it's a common refrain is the sort of broad spectrum of things we get to see, no pun intended. How about you, Vidya?

Vidya Sundareshan: [00:02:01] So I have enjoyed studying biology right from elementary school and with a fascination for medicine and white coats in particular. Completed medical school from India. About 25 years ago, I came to the US to pursue a master's in public health. The course and some amazing people I met along the way expanded my mind and introduced me to this mind-blowing specialty of infectious diseases. The specialty best represented the intersectionality of public health and clinical medicine. So I got an internal medicine residency and completed fellowship training in infectious diseases.

Paul Sax: [00:02:37] Well, listen, thank you for joining us to talk about these practical issues. International medical graduates. Can you explain the visa types we commonly see among trainees and junior faculty in ID, and pretend that your listeners know nothing about this?

Vidya Sundareshan: [00:02:52] I'll start us out with defining what an international medical graduate is. This is someone who has gone and attended medical school outside of the United States. Could be someone who is a United States citizen and has attended medical school outside as well. So with that in mind, the two common non-immigrant visas for residency or fellowship training are J-1 and H-1b visas. The J-1 visas, described as an exchange visitor or trainee visa and in the participants for a J-1 visa could be students, scholars, trainees, specialists. Typically a seven year duration, and it has a two year foreign residency requirement, where the exchange visitors are required by law to return to their home country or most recent legal permanent residence for two years, and that is with the purpose of sharing the knowledge that they have gained in the United States. Or they can secure a waiver based on one of the four grounds that they can apply this way before. And the most common way for pursuing that waiver as a recommendation by an interested government agency. The second type of visa is a H-1b, and that is a professional worker visa that's sponsored by an employer for a specialty occupation. Now, the employer needs to file a labor condition application, and it doesn't require the home rule or home return rule, but it does need this uninterrupted employer sponsorship, and it can last for a maximum of about six years. And I'd also like to mention a third route, which is an O-1 visa, or an outstanding visa for individuals with extraordinary abilities, indicating that this person is one of a very small percentage that has received a major international or national recognition for excellence in the field of endeavor. Not very common as a route for trainees right out of fellowship.

Paul Sax: [00:04:54] What percentage roughly if you have this data are on J-1 visas versus H-1b visas, when we're talking about ID fellows.

Vidya Sundareshan: [00:05:03] I would speculate it's about 30% or so that are on visas currently. I would think there are more H-1b visas than J-1.

Alfredo Mena Lora: [00:05:12] I'm not sure the numbers, but the J-1 is certainly, it doesn't have a cost to the institution. It's a very easy process. So in my experience, the J-1 is the most common one and the H-1b is the exception. But it might vary in geographic regions and different cities. But the J-1 is certainly a more streamlined and easier process, and more cost effective, at least at my site, is the most common one.

Paul Sax: [00:05:34] Often, the trainees are advised to engage with a lawyer, and the hospitals provide an immigration lawyer. Should they also get their own representation?

Alfredo Mena Lora: [00:05:43] Yeah, when my fellows are looking for a job and, uh, that's kind of one of the first questions that come up. There's a lawyer, they're giving me some great advice, and it is pretty common for trainees and even my own friends when they were going through this process to just continue with that lawyer there in charge of doing the paperwork. They will kind of take the process forward. I always advise folks to develop a relationship with their own immigration lawyer, because at the end of the day, that lawyer works for the hospital. They will be in charge of that paperwork, but they really represent their interests. There's another big reason to have your own lawyer, which is just the cumulative experience of having dealt with so many different people doing the same process in different states. That particular lawyer may have just the experience of that hospital. So that's why I think it's always better to have your own lawyer.

Paul Sax: [00:06:28] And what about the hurdles that the ID fellows on visas face coming to the end of their fellowship or even beforehand? And, you know, they need to think about what's next?

Vidya Sundareshan: [00:06:38] Visa and job landscape is ever changing. So on a personal level, one needs to be aware of the various resources that are available. One has to be proactive to look for what's changing and what is really applicable to that particular individual. A fellowship, leadership, or institutional level. The stakeholders may not always be educated about the next best steps for each fellow, and there may be no immigration office in many institutions for guidance. You know, in situations like that. Alfredo was mentioning having their own lawyers may be helpful as well. The biggest challenge, however, is not every employer is really able to sponsor visas. So there are lesser job opportunities for people who are requiring visas. So one has to be really well informed and proactive to find these visa friendly institutions in the search process.

Alfredo Mena Lora: [00:07:33] Another big issue is timing. So for J-1 visa holders, the process of getting a Conrad 30 waiver can take many months. And just as a kind of advice, you might be working with colleagues who are not going through the same process. So they might be looking for a job much later than you. It takes at least 12 to 18 months before graduation to start the process. You know, it's really important. And what is the Conrad 30 waiver? So Vidya was mentioning how it's an exchange visa, you know, pretty straightforward and streamlined to come and train, but you're supposed to go back home to your country to share that expertise. The waiver is to waive that requirement. You can waive that requirement by staying in a hospital, in a community that has a specific need. And that, of course, will change in different states. But that's the process, and it takes some time.

Paul Sax: [00:08:19] When you want to go right into a job with a J-1 visa, someone has to file for a Conrad 30 waiver. Is that right?

Alfredo Mena Lora: [00:08:27] That is correct. For J-1 visa holders, you need to find an employer that is willing to sponsor a Conrad 30 waiver or any other waiver program. There's different ways to move away from that requirement. There are different forms to find a waiver, but the Conrad 30 is one of the most popular. One of the most common ways. The 30 is because there's 30 spots in each state. It often means looking in medically underserved areas. Be able to find healthcare workers in areas of need.

Paul Sax: [00:08:52] So this is a way of bringing workforce to places that have greater need.

Alfredo Mena Lora: [00:08:58] That is correct. There is a slight difference with H-1bs. If you are already in training with an H-1b, then you don't have that two year requirement. So you don't need a waiver. You still need an institution that is willing to sponsor H-1b extensions, and that typically has its own set of requirements.

Paul Sax: [00:09:13] During fellowship, especially during the second year. Sometimes fellows want to moonlight, you know, are there any restrictions among visa holders?

Alfredo Mena Lora: [00:09:21] I think it's very important to be informed. The best way to advocate for yourself is to be informed and talk to your program director about these many restrictions, and moonlighting restrictions is certainly an important one. It's a very strict restriction for J-1 visa holders, but for H-1bs, though you can work in other places, you still need permission. You need somebody to sponsor essentially a separate H-1b.

Paul Sax: [00:09:42] Wow. I know that this is also a struggle with federal funding for research grants, that certain grants are not accessible to people who are here on visas. You've already alluded to this, but Vidya, maybe you can give us a little bit more information about when the process should start, when you're talking about getting a job.

Vidya Sundareshan: [00:10:03] Ideally towards the end of the first year of fellowship. One should start looking. The process really takes time, and if seeking out a Conrad waiver, then the paperwork takes time. You have to find those positions. You have to look to apply to the states, which will have those positions open. Just as a reminder, these Conrad 30 positions that are open are not just for ID or not just for internal medicine. So you're competing with vascular surgeons or other specialties as well. So it is very limited. So the search has to start very, very early, preferably at the end of first year of fellowship. The paperwork is filed by October of the following year. And then they get to know by December if that position is approved or not.

Paul Sax: [00:10:49] It seems that some places are more optimistic about getting these approved than others. Is that because they've been allotted a certain number of the visas?

Vidya Sundareshan: [00:10:57] Can differ from state to state, but typically it is 30 positions, and it can vary from year to year to, you know, like Alfredo was mentioning, it's it's a medically underserved area or where the need is where there is a shortage of healthcare professionals. Based off of that, it can vary from year to year as well. Places which have had a lot more experience for applying for these waivers. They have a process in place and it's definitely easier for them.

Paul Sax: [00:11:26] Maybe you can comment, Alfredo, about the difference between going into academics versus private practice versus whatever.

Alfredo Mena Lora: [00:11:36] Absolutely. So think about these visas, both J-1 and H-1b, with or without their waivers. They're very location and population dependent. So you need to know where you're working, what type of employment it is, what type of organization like, for example, nonprofit, you know, underserved areas. Et cetera. So for private practice, it is a little bit harder to find jobs because they may be working with an underserved population, but as an organization they may not be non-for profit. So there's all of these different nuances, and ultimately a hospital employed or academic job might more easily fit these criteria.

Paul Sax: [00:12:14] So let me ask you about another consideration, which is that, of course, people who are wrapping up their ID fellowship are also starting their families around the same time. They may be already married. They may already have children. What are the considerations there?

Alfredo Mena Lora: [00:12:28] In general, for spouses of physicians that have J1 throughout their training, it's much easier to get work authorization. For H-1b physicians, it's a little bit harder. The reason for this is the J1 is really, you know, think about it as an exchange visa. They kind of understand your circumstances a little bit more. There's of course this waiver that you need afterwards. But for H-1b it's an employment based visa. So the person here is the individual contracted to do this work, which is the physician. The spouse would need their own H-1b to proceed and work. So it's a little bit easier for J1's a little bit harder for H.

Paul Sax: [00:13:04] Okay. Now let's shift to telling some personal stories. I don't know who wants to go first, but you must know some people very well who have navigated this process.

Alfredo Mena Lora: [00:13:14] Absolutely. And I can start with my story, a little parenthesis on talking about all of these things. So when Vidya was mentioning the Conrad 30 waiver and how it's different in every state, I really received a lot of great information from my personal immigration lawyer because they had experience applying in different states and with different people. That cumulative experience really helped. So inform yourself is kind of my most important advice and to be able to advocate for yourself. So my experience, I'm from the Dominican Republic originally, and I trained under a J-1 visa. I went through the Conrad 30 waiver, and the way that I tried to advocate for myself was to look for opportunities and double check everything myself. This job is eligible. So I talked at my university and confirmed things, and with that, I was able to find an academic job and be able to pursue, you know, with a lot of luck. Um, I was able to find Conrad 30 waiver that would fit my ideal career plans. So it is feasible, and I've been able to advise my fellows who have also found a lot of great job opportunities in academia and in hospital employed positions.

Vidya Sundareshan: [00:14:17] So my story is transitioning from H-1b to permanent residency. I've been in different types of visas. When I came to the United States from India 25 years ago, I was on an F-1 visa, or a student visa, for a master's in public health. I had a chance to transition to something called optical optional practical training. I was able to do that for one year, following which I did residency on a J2, which is the spouse of a J-1 visa holder.

Paul Sax: [00:14:47] Give me that. What is that?

Vidya Sundareshan: [00:14:49] So it's J2, J2, or spouse of the exchange visa holder. And then halfway through residency, I was not eligible for J2 anymore because my husband's status changed. So halfway through residency, uh, with the help of a very compassionate and knowledgeable GME staff of, uh, the place I was doing my fellowship in, I was able to transition to an H-1b. Now, when I started my job on H-1b with, uh, dual intent. And that just means that I'm allowed to work while I'm pursuing various steps that are involved in, uh, permanent residency. Finally became a lawful permanent resident 11 years after that application.

Paul Sax: [00:15:33] I have to say, both of you, with your experience personally and then now experience with trainees, you must be very aware of common pitfalls. So what can you warn us about, Alfredo?

Alfredo Mena Lora: [00:15:48] I think the three main warnings is missing deadlines, travel restrictions and moonlighting and those sort of violations that you could do without realizing it. So other folks, people who might employ you, people who might work with you, they may not be aware of these things. So ultimately, it's up to you to try to be as informed as possible. So starting with missing deadlines. If you are a first year fellow, know your visa type. Know your process towards finding a job. As we mentioned earlier, that might start a year before your co-fellows. As a program director, I talk to my fellows and try to inform them about this as well, but it's important to keep that in mind. For travel restrictions, certain visa holders can't leave the US easily. Particularly for J visa holders, you're in this kind of annual resubmission of your paperwork, and therefore your passport may not have an up to date visa stamp, even though you are up to date. You're okay, you're doing fine. But in order to travel, you have to make sure you can go to a consulate and get your visa stamp in. So traveling is just more complicated and you have to be aware of those different pitfalls. And then last but not least, moonlighting. Make sure that you understand what you can and can't do so you don't accidentally do something that you shouldn't have.

Paul Sax: [00:16:59] So will they be able to find your moonlighting records in the process of trying to get a Conrad waiver, for example?

Alfredo Mena Lora: [00:17:07] I'm not sure. I think it's possible, certainly, since any sort of employment gets reported and that is essentially employment without authorization. You know, you can do things and volunteer, particularly opportunities that might require payment, like giving a lecture or something, but certainly any sort of payment and things like that that could be, you know, a violation you should avoid.

Paul Sax: [00:17:27] Sounds like it never hurts to ask whether it would be a violation. So, you know, I hardly need to tell these two practicing ID doctors, and I'm a practicing ID doctor that we're in a time of enormous political change. What do you see as shifting landscape now? What's going on?

Vidya Sundareshan: [00:17:46] As of yet, there are really no major changes. There are some anticipated changes or something to look out for in the H-1b policies or increased restrictions on the waiver programs. Processing times may be a little bit longer because of changes in staffing at agencies and consulates.

Paul Sax: [00:18:07] Yeah, I mean, I think one of the big concerns I have about staffing reductions in the federal government in general is that it will make processes that were never known for their efficiency even less efficient. This is really a huge concern across the board, and I can see how it would apply to this area as well. Both program directors, what can you do to support your trainees who are on visas?

Vidya Sundareshan: [00:18:31] I would say that it's very important to advocate for policies which make visa processes easy to navigate, as it is such a stressful time to find a job. So having those processes in place will definitely be helpful, and especially with the critical workforce shortages, we know that there is a pool of really exceptionally qualified candidates that can be part of our workforce.

Paul Sax: [00:18:54] Oh, yeah. Every program, of course, has international medical graduates who do outstanding work become a critical part of the ID workforce going forward. So we really value this contribution. Anything else, Alfredo?

Alfredo Mena Lora: [00:19:09] Yeah, there's a couple of things. Kind of going back to the different pitfalls that I mentioned that I always try to counsel, combining what I said and what Vidya said. Be careful with travel. The timing that it might take. The appointment times in a particular consulate. Making sure that you're always maintaining status, which is fancy immigration law term of being compliant and always, you know, being on top of your things. Weigh in any travel with possible risks. It might not fall in the right time during your immigration process or renewal process. I had to cancel a few trips myself of things that I wanted to do with my family abroad and couldn't. So it's always important to weigh in those risks and always consult an immigration attorney. And establishing that relationship will help you throughout your process. Beyond that first job, once you're doing the permanent residency and other things as well.

Paul Sax: [00:19:56] And where can people go to find help? I mean, this is a seems like an overwhelming challenge. I would hope that there are resources available.

Alfredo Mena Lora: [00:20:04] There are resources and IDSA, ABIM in health and networking. Just talking to people that have gone through this, whether it's your program director, your colleagues, and yes, your immigration lawyer, because that person has the cumulative experience of so many people just like you. But there's a lot of professional groups within our society, groups like Latinos in ID, South Asians in ID, they can offer support and mentorship.

Vidya Sundareshan: [00:20:29] And I'd also like to give a quick shout out to, uh, the Febrile Podcast episode 113, season four finale on supporting IMGs in ID, which is an excellent resource.

Paul Sax: [00:20:40] We had one of our fellows give a really outstanding review of this topic at our weekly ID grand rounds. It was really special. And one thing that was clear to me was that it takes enormous talent in executive function to carry this out. Planning deadlines, contacting the right people, paperwork control. I have enormous admiration for anyone who can get through it successfully. So congratulations to you both. Any last words of advice?

Vidya Sundareshan: [00:21:09] Stay informed. Start early. Proactively seek out opportunities. Do not forget to lean on mentors who've already been through this.

Paul Sax: [00:21:18] Thanks very much for those wise words. So we have been talking with Dr. Vidya Sundareshan and Dr. Alfredo Mena Lora, both of whom have played key roles in helping their international medical graduates become part of the ID workforce. Thanks to both of you.

Alfredo Mena Lora: [00:21:37] Thank you very much.

Vidya Sundareshan: [00:21:38] Thank you.