International Medical Graduate (IMG)

What is an International Medical Graduate?

An International Medical Graduate (IMG) in the United States is a physician who has graduated medical school from outside of the United States or Canada.  They comprise about 25% of the U.S. physician workforce.

An IMG may be a U.S. citizen or permanent resident (“Green card” holder), or a citizen of another country.

An IMG applying to subspecialty fellowships may have completed an ACGME accredited residency, or may have completed residency-equivalent training abroad.

What is ERAS?

The Electronic Residency Application Service (ERAS®) transmits applications, letters of recommendations, performance evaluations, transcripts and other supporting material from applicants to program directors. ERAS is supported by the Association of American Medical Colleges (AAMC).

What is NRMP?

The National Resident Matching Program® (NRMP®) is a non-profit organization that supports a standardized residency and fellowship selection process. The NRMP manages the Main Residency Match® and the Specialties Matching Service® (SMS), which includes matches for more than 40 subspecialty fellowships, including Infectious Disease.

What is ECFMG?

The Educational Commission for Foreign Medical Graduates (ECFMG, https://www.ecfmg.org  ) is the organization which certifies IMGs’ credentials. They are designated by the Department of State to sponsor physicians requiring J-1 visas for medical training.

What is ACGME?

The Accreditation Council for Graduate Medical Education (ACGME, https://www.acgme.org  ) sets and monitors compliance with standards for internship, residency and fellowship programs across all medical specialties in the United States.  They accredit programs and ensure the education program meets standards.

What is ACGME-I?

ACGME-I is the international arm of the ACGME.  They provide voluntary accreditation to medical training programs outside the United States.

What is ABIM?

The American Board of Internal Medicine is the not-for-profit organization which oversees board certification in internal medicine and its subspecialities, including infectious diseases and nephrology.  www.abim.org

What are licensing requirements for training?

There are 71 MD and DO licensing boards in the United States. Each jurisdiction has specific requirements which may differ whether you are applying for a training license or a full, unrestricted license.  Visit https://www.fsmb.org/contact-a-state-medical-board/ to find the medical board for your jurisdiction.

The Federation Credentials Verification Service (FCVS) is a service of the Federation of State Medical Boards (FSMB) to store and verify core medical credentials such as diplomas, transcripts, Medical Student Performance Evaluations (MSPE or “Dean’s Letter”).

One advantage for an IMG to use FCVS is that many state boards will accept medical school credentials verified and stored by FCVS, reducing the need to provide original documentation for subsequent license applications.

When applying for a job, all the state licensing boards require verification of the credentials. FCVS is a convenient method of preserving essential qualifications that can be utilized across various state medical boards. These boards depend on this standardized and centralized system to acquire education information that has been verified from primary sources for individuals seeking licensure.

Kentucky, Louisiana, Maine (Medical), Massachusetts, Nevada (Osteo), New Hampshire, Ohio, Rhode Island, South Carolina, Utah (Medical), Utah (Osteo), the Virgin Islands and Wyoming require an FCVS Profile for all applicants for licensure.

New York and North Carolina require FCVS Profile for IMGs

All states accept FCVS credentialing.

The majority of US GME programs will sponsor a J-1 visa; an H1-B visa may be sponsored if specifically requested by the applicant. Upon completion of training in the US, J-1 visa trainee holders must return and work in their home country for 2 years before becoming eligible for any immigrant or temporary worker visa like H-1B. A J-1 visa can be extended for a maximum of 8 years.  Applicants for an H-1B should have passed all 3 steps of the USMLE.

Although less common, some GME programs will sponsor trainees to obtain H-1B visa. An H-1B visa is for temporary workers in specialty occupations including medical professions. H-1B visa does not have the 2-year home residency requirement; however, it can only be extended for up to 6 years.

Table 1: Comparison of J-1 and H-1B visas

The majority of the programs in the US do, especially as ECFMG (Educational Commission for Foreign Medical Graduates) sponsors J-1 visas. However, if you are on H1-B visa status prior to joining a fellowship, you should specifically disclose and consult with the fellowship training program about further sponsorship.

Check the FREIDA database for this information: https://freida.ama-assn.org/

A J-1 waiver job is usually offered in areas that are considered to be ‘medically underserved’ for a particular field. The most common J-1 waiver scheme, the Health and Human Services Exchange Visitor Program (aka Conrad 30), each state has a limit of 30 waiver positions.  However, some states’ Departments of Health may use up to 5 of its 30 annual J-1 waiver slots to place physicians in geographic locations which are not medically underserved provided patients who reside in medically underserved areas will be treated by the physician. The slots are known as the “FLEX 5″ slots. Use of these slots is entirely within the discretion of the state department of health and states who do not use all of their 30 slots are likely to be the most receptive to using the FLEX5 slots. 

Other J-1 waiver schemes are discussed below.

The following waivers are alternative pathways to Conrad-30. There is no cap on the number of applications approved in each state. Applications are reviewed all year.

1. Interested Government Agency (IGA) waiver: This waiver is for physicians who have employment offers from US governmental agencies like National institute of Health (NIH), Veterans Affairs, or the CDC. The agency can submit a request on the physician’s behalf.
2. Appalachian regional commission (ARC) waiver: to obtain this waiver, physicians must have a job offer from a healthcare facility located in the Appalachian region which includes a limited number of counties in 13 states.
3. Delta Regional Authority (DRA) waiver: similar to ARC waiver, physicians must be sponsored by employers in the delta region which includes Alabama, Arkansas, Illinois, Kentucky, Louisiana, Mississippi, Missouri and Tennessee.
4. Southeast Crescent Regional Commission (SCRC) waiver: a new program that started in 2022 which accepts waiver requests in facilities located in Virginia, North Carolina, South Carolina, Georgia, Alabama, Mississippi, and all of Florida.
5. The US Department of Health and Human Services (HHS) waiver: this waiver is for physicians who seek positions in mental health or primary care. Physicians commit to work in health professional shortage areas (HPSA) for 3 years. Physician graduation from their residency program must be no more than 12 months before the date of employment.
6. Hardship waiver- An individual applicant may petition for a waiver if departure from the United States for 2 years would place an undue hardship on the applicant’s US citizen/permanent resident spouse or child.  Consultation with a qualified attorney is recommended.
7. Persecution waiver–An individual applicant may petition for a waiver if departure from the United States to their home country would place them at risk for oppression based on race, religion or political beliefs. Consultation with a qualified attorney is recommended.

There are J-1 waiver spots across the country that might be the best fit for you (which needs a bit of research). However, most of them are in underserved areas and preferably for primary care physicians or internal medicine doctors.

Hence, it can turn out to be competitive to land a J-1 waiver spot for a subspecialist, especially in your location of choice.

Under the Health and Human Services Exchange Visitor Program (aka Conrad 30), each state has a limit of 30 waiver positions. The method in which spots are allocated is determined by each state, and thus varies across the nation. It is important to learn about waiver timelines and application process in your state of interest when looking for a waiver position. The best advice is to apply early during each application cycle.  

If you wish to go into academics after fellowship, this may be somewhat more challenging to do on a J-1 waiver. Although there are some academic institutions that can sponsor J-1 waivers, most waiver positions are available in community hospitals/clinics. Keep in mind that a waiver is a three-year minimum contract, so it is possible to move into academia once you have completed your waiver. The process of transitioning to permanent resident status (Green card holder) begins after you fulfill the 3-year waiver requirement and it lasts ~2 or more years depending on your country of birth.

The situation will vary from person to person depending on their personal and professional circumstances. Some will consider long term academic goals. Some candidates might have to take their financial situation into consideration, also your visa situation is a telling factor. For example, IMGs from countries like Mexico, Philippines, India, and China especially might have a wait time of many years prior to obtaining  permanent residency status in the US, which might be crucial especially if they have a family.

Also important to note for J-1:

In order to maintain J-1 visa status, you must transition directly to another training program. Therefore, fellowship should be pursued immediately after residency. Alternatively, it is also possible to complete a J-1 waiver after residency and transition to a different visa or permanent resident status for fellowship afterwards.

Typically, you should begin the search for a J-1 waiver position 1.5 years before you graduate.

The majority of job openings are listed with criteria as “Board certified or board eligible”. To our experience, larger tertiary and academic hospitals tend to prefer experienced candidates, with probably a few years of experience post-graduation or with teaching experience.  Board eligibility is often acceptable, but board certification always adds strength to your application.  Most employers will want you to be board certified within 3 years of hire.

When looking for J-1 positions, it is helpful to use various job search websites (see below). Keep some criteria in mind and use filters to help narrow your job search (for example location, inpatient vs. outpatient, call schedule). Most job postings will specify whether a J-1 visa waiver can be sponsored, but it may be worth reaching out to the recruiter for further details if a job is of particular interest. Health systems can cover a broad region and may support J-1 waivers at certain clinics/hospitals, despite not advertising this.

80% of US counties don’t have ID physicians (Walensky et al.  Ann Int Med, 2019).  Similarly, there is a mismatch between supply and demand for nephrologists in parts of the United States (Fraher et al, ASNData, 2017).  For this reason, you may ask if a J-1 waiver position is negotiable even if it is not advertised as such. There are multiple ways of obtaining a J-1 waiver position, however it can be tricky to obtain a perfect matching job. It is always recommended to seek advice from an attorney who is versed in J-1 waiver positions. It is prudent to have your attorney work closely with the hiring hospital’s attorney.