ASA May 2003 Newsletter

For many young international medical graduates (IMGs), especially those interested in anesthesiology, there exists a great opportunity for coming to the United States to further their medical education. The Immigration and Nationality Act (INA) provides a nonimmigrant visa category, the J-1 visa, for persons to participate in exchange visitor programs in the United States.¹ The J-1 visa is for educational and cultural exchange programs designated by the Department of State. For IMGs coming to the United States, J-1 status allows their participation in residency and fellowship training programs. This opportunity is particularly important in anesthesiology since the projected shortage of anesthesiologists in the United States is expected to continue through 2005.² Exchange visitors coming under the “J” program for graduate medical education or training must meet certain credentialing requirements prior to obtaining Educational Commission for Foreign Medical Graduates certification. This includes demonstrating competency in English and having successfully completed United States Medical Licensing Examination (USMLE) steps one and two and the clinical status exam. An IMG in J-1 status can pursue up to seven continuous years of graduate medical training in the United States upon matching with a training program. According to a recent survey, approximately 142 CA-3 residents are in J-1 status.³

IMGs also may participate in graduate medical training in H-1B status as long as they have successfully completed USMLE step three in addition to the other requirements. The H-1B allows a physician to work in the United States for three years and is renewable for an additional three years, at which time, the holder may apply for permanent residency (a green card) to remain in the United States. However, the H1-B is employer-sponsored and site-specific and requires an extensive application from the hosting institution. Therefore, many institutions do not sponsor H1-B visas.

Coming to the United States in J-1 status has one major disadvantage when compared to pursuing graduate medical training in the United States in H-1B status. With a J-1 visa, the IMG is automatically subject to the requirement that he or she return to his or her home country for two years before being eligible to obtain H, L or an immigrant visa in the United States.⁴ In certain circumstances, a waiver of the two-year home residence requirement may be available from the Bureau of Citizenship and Immigration Services (BCIS).

The options for a waiver are based on exceptional hardship or persecution and are available through an interested government agency.⁵ One of the most popular routes for IMGs seeking a waiver of their two-year home residence requirement is through the sponsorship of an interested state or federal government agency. Federal J-1 waiver applications are processed most frequently through the Veterans Administration (VA), Appalachian Regional Commission and, most recently, the Delta Regional Authority. On the state level, almost all states, Guam and the U.S. Virgin Islands process J-1 waiver applications through a program called the Conrad State 30 Program.⁶ In exchange for a waiver of the two-year home residence requirement based on a recommendation to the U.S. Department of State and BCIS, the IMG must thereafter complete three years in the medically underserved area in H-1B status. The survival of the Conrad State 30 Program is therefore essential to IMGs if they are interested in pursuing a waiver of their two-year home residence requirement.

Continuation of the Conrad State 30 Program came under serious threat last year. The Immigration and Nationality Technical Corrections Act of 1994 originally stated that the Conrad State 20 Program, as it was then known, was to sunset June 1, 2002.⁷ This meant that all IMGs entering the United States, or those who acquired J-1 status for the first time after June 1, 2002, would no longer be able to participate in the Conrad State 20 Program. For anesthesiologists, as for other subspecialists, this would have severely limited the avenues available for pursuing a waiver of their two-year home residence requirement.

Fortunately, legislation was passed by the U.S. Congress and signed by President George W. Bush on November 2, 2002, extending the duration of the program until June 1, 2004, and at the same time, increasing the number of waivers each interested state government agency can approve in a fiscal year from 20 to 30. This increase in waiver numbers results in a nationwide increase of roughly 500 J-1 waiver jobs for physicians each year. These changes can be found in section 11018 of the 21st Century Department of Justice Appropriations Authorization Act (Public Law number 107-273).

While this legislation was crucial to the continuation of the Conrad State 30 Program, the program is again due to sunset in June 2004. This means another concerted effort will need to be made between private employers, trade associations, community medical providers, hospitals and other affected parties who require the medical services of IMGs in medically underserved areas of the United States and their representatives to Congress to continue the Conrad State 30 Program. New legislation will need to be passed by Congress, and action will need to be taken soon.

References:

1. INA § 101(A)(15)(J), also cited as 8 U.S.C.A. § 1101(a)(15)(J).

2. Schubert A, Eckhout G, Tremper K. An updated view of the national anesthesia personnel shortfall. Anesth Anal. 2003; 9(1):207-214.

3. ibid. 2

4. INA § 212(e), also cited as 8 U.S.C.A. § 1182(e).

5. ibid. 4

6. INA § 214(1), also cited as 8 U.S.C.A. § 1184(1).

7. 8 C.F.R. § 212.7(c)(9)(i)(A).

Alá Sami Haddadin, M.D., is a postdoctoral fellow in Adult Critical Care Medicine and Cardiothoracic Anesthesia, Johns Hopkins Medical Institutions, Baltimore, Maryland.

P.Montserrat C. Miller, Esq., is an attorney with Pederson & Freedman, LLP, Washington, D.C.

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