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He has now been waiting for more than eight years and has no idea how much longer it will take, since USCIS is only processing people who have a priority date of April or earlier.

Immigrant Doctors Can Help Lower Physician Shortages in Rural America

Since most of these children have grown up and received an education in the United States, it makes no sense to place barriers on their career and educational aspirations. When they apply to college, they will not have access to federal scholarships and federal student aid. She came with him to the United States as a 1-year-old and is one of the top students in her high school class. Yet when she applies for college, she will most likely be subjected to all the restrictions that come with being an international student.

For immigrant doctors, earning a license to practice in the United States is a complicated, lengthy process that they must go through at the same time as maintaining their immigration status and making sure they have enough earnings and funds available to take care of themselves and their families. Currently, each state has varying requirements for granting international medical graduates a license to practice. While standardized licensing processes help protect public safety, there is significant variation in requirements among states, with some being far more restrictive than others.

The ways in which states implement their Conrad 30 Waiver Program differ widely. Each year, states can apply for 30 waivers to recruit immigrant doctors who have completed their residencies under J-1 visas. Most or all of the 30 waivers are awarded to physicians who agree to work in federally underserved areas.

Many states, such as Iowa and Maine, also have up to 10 flexible waivers that allow physicians to work in a facility that is not in a federally designated underserved area but still serves patients who live in underserved areas. Other states, such as Tennessee and Virginia, have five flexible waivers. Meanwhile, in states such as Alabama and Arizona, there are no flexible waivers. Furthermore, there are differences in how states define primary care and what subspecialties are accepted for these waivers. There are several ways in which rural communities can recruit and retain immigrant doctors and build lasting relationships with physicians who settle in their localities.

Research shows that many immigrant doctors practicing in rural communities end up staying in those areas even after they have met their three-year requirement under the J-1 waiver. For example, among immigrant doctors in Iowa with a J-1 waiver under the Conrad 30 program, 92 percent completed their three-year requirement, and 68 percent remained at the original site for four or more years. Legislative changes at the federal level are needed to simplify and strengthen the various pathways through which physicians can practice in these high-need areas.

Beyond these policies, states must also take action to reduce barriers to licensing for immigrant doctors to practice and settle in their states. The following policy recommendations are just a starting point to breaking down barriers for immigrant doctors to serve in rural areas and improving retention.

Although immigrant doctors generally use J-1 or H-1B visas to train and practice in the United States, neither category is flexible enough to easily accommodate years of required residency trainings, allow physicians to practice after completing their training, and provide immigrant doctors with an easy pathway to permanently settle in the United States.

If the United States wants to effectively tap into this talent to tackle the shortage of physicians in rural communities, more needs to be done. The Conrad 30 Waiver Program is one avenue through which immigrant doctors under the J-1 visa end up practicing in rural areas after completing their residencies. Currently, however, Congress extends the program inconsistently, from a few months to as long as a few years, making it an unreliable avenue through which to recruit physicians.

States offer only 30 J-1 visa waivers per year under the Conrad 30 program, regardless of the demand for physicians or the size of the state. About half of states generally use their allotted 30 slots every year, while the other half do not use them all. Especially after the recession, employers found the cost of applying for an H-1B visa prohibitive and started opting for J-1 visas instead. This meant that there were more J-1 physicians who were searching for positions and applying for the Conrad 30 program. The federal government should either remove the restriction entirely or increase the number of slots available to make it easier for states to offer enough waivers to meet demand.

The bipartisan Senate bill passed in —S. With more options, it would also be easier for physicians under J-1 waivers to find positions that are good fits for them. This is extremely restrictive for physicians who would like to move away from a site due to reasons that do not qualify as extenuating circumstances.

These doctors may find that their place of work is not conducive to growth, that they do not get along with their colleagues, that they dislike how the facilities are run, or that they simply dislike the work culture.


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Yet under U. Citizenship and Immigration Services rules, such work issues are not reason enough to allow an immigrant doctor to change employers. Chivukula, one of the few geriatric psychiatrists in West Virginia, practiced in Fairmont for about eight years. While he built strong relationships with his patients, he was not satisfied with his position; during his time in Fairmont, his employers never talked about career growth or salary changes. But due to the restrictions tied to his J-1 visa waiver, he could not change his employer, move to a facility close by that also served an underserved area, or grow his practice.

But even within the limits of a J-1 waiver, he managed to serve more people by getting involved in another project at a university in the area, where he ran a memory clinic. Allowing physicians such as Dr. Chivukula to change their employers would provide them some relief and freedom to seek out other, more fulfilling positions. Other doctors who are waiting for green cards under H-1B visas share these sentiments. For example, a nephrologist in Mississippi relayed that because his status was tied to his employer, it prevented him from starting his own practice and doing more for his patients.

In recent years, there have been more petitions filed for H-1B visas than there have been visas available. Moreover, these visas have been allocated through a random lottery system—which is not a particularly strategic way to allot any visa. The H-1B allocation process needs to be reformed in a way that is advantageous for both the country and its workers.

For example, it should give preference to petitions from employers in areas and occupations experiencing high shortages. This would make it easier for rural health care facilities that have trouble finding doctors to recruit immigrant doctors under H-1B visas.

Furthermore, bills have been introduced in Congress to reform the program in a way that would protect wages for all workers. In , Rep. Zoe Lofgren D-CA introduced legislation designed to recruit highly skilled and highly paid workers who would complement the U.

[USC02] 8 USC Admission of nonimmigrants

Waiting for a green card is a long and arduous process, especially for immigrants from large countries such as India and China. Fortunately, a number of bills have been introduced in both the House and Senate to remove per-country limits or at least attempt to improve the application process for certain doctors.

For example, S. Currently, incentives to apply for a NIW and spend five years in a rural area instead of a suburban hospital are diminished because of the long wait times regardless of whether people receive an H-1B and practice anywhere or get a NIW and commit to stay in a rural underserved area. To avoid increasing the current wait times for applicants from smaller countries, the existing backlogs in high-shortage occupations need to be cleared and per-country caps need to be eliminated.

Moreover, the new system should give preference to applicants on the basis of their filing date or on a first-come, first-served basis. Such a change in policy would provide relief to thousands of individuals and families who have been waiting for their time to come, but it would not delay current applications.

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However, it will be difficult to truly prevent future backlogs without increasing the total number of green cards available each fiscal year. Many immigrant doctors whose immigration status is in limbo believe that if they had green cards, they would be able to do more with their expertise, getting involved in more projects and serving more people. Reema, a child psychiatrist in West Virginia, shows what happens when physicians have stable immigration status and can work toward bettering themselves and their communities.

Ten years ago, while still on a J-1 waiver, she began noticing the impacts of substance abuse and the opioid crisis in very young children. As a child psychiatrist, she often saw preschoolers with severe behavioral problems. They often were exposed to opiates before birth and had chaotic living situations early in their childhood. There were not many services available in the community to help such families. At that time, Dr. Reema remained on her H-1B visa while waiting for a visa to become available under the EB-2 category. However, since an H-1B visa holder is only able to work for the sponsoring organization, she could not contract with another organization and was limited to the job description provided by her employer.

Changing jobs would have meant finding an employer willing to sponsor her H-1B visa and take over her green card processing. She had limited options in the community where she lived, and moving meant uprooting her family. She ultimately decided to join a university that was willing to work with her and her attorney so that there would not be a lapse in status. The position at the university allowed her to get involved in more targeted work related to the opioid crisis. She, along with a group of doctors and community leaders, decided to focus on the unique needs of children and babies who have been affected by substance abuse and the opioid crisis.

Over time, this group started to partner with different community groups—including day care centers, pediatric units, OB-GYNs, the city government, and churches—to educate them about substance abuse and involve them in a continuum of programs. The work group applied for grants and used those funds to provide services for young families and children affected by substance abuse. In one of the programs, for example, social workers and substance abuse coaches are paired with pregnant women or mothers of young children to provide them with the support, guidance, and services they need to navigate their lives.

This support system helps mothers and prospective mothers find transportation; apply for the Special Supplemental Nutrition Program for Women, Infants, and Children WIC ; and secure resources available in the community. In another new program, the work group has partnered with a facility to provide day care services for babies who had withdrawal symptoms at birth because their mothers had substance abuse problems; these unique needs demand specialized care.

Permanent Employment-Based Immigration and the Per-Country Ceiling *

The work group is involved in many other similar programs to serve disadvantaged children and young families affected by the recent drug abuse crises. While Dr. Reema was getting involved in all this great work, she was also working though her green card process. The EB-2 category has a lengthy wait time, and with her H-1B clock running out at nine years, she also applied on her own in the EB-1 category, which has a relatively shorter wait time since it is for individuals with exceptional abilities. Federal solutions can greatly and permanently improve the ways immigrant doctors can help reduce health care shortages and increase quality of care in rural areas, but states and localities can also do a lot more to remove barriers to attract and retain immigrant doctors.

Getting rid of unnecessary red tape and restrictions; equalizing policies; and, at the end of the day, treating physicians as people who are looking for advancement will help states retain physicians and ultimately improve health care access. Some state governments have formed task forces to identify roadblocks that prevent immigrant doctors from re-entering their profession.

Physician shortages disproportionately affect rural communities

For example, Minnesota, under Minnesota Session Laws, established a task force of diverse groups that released a report identifying barriers for immigrant doctors and crafted a set of policy recommendations. To address these barriers to increasing health care access in rural and underserved areas, Minnesota created a program called the International Medical Graduates Assistance Program.


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Other states should follow the lead of Minnesota and Massachusetts and methodically study their own health care needs to determine how immigrant doctors are contributing—and how they could contribute more if significant roadblocks were removed. All doctors, regardless of where they are trained, must pass the same national U. Medical Licensing Examination before they can practice in the United States.

And medical graduates are also required to go through residencies. For immigrant doctors, clinical trainings received abroad do not fulfill this requirement, no matter how many years they have spent in residencies after receiving their medical degrees. For example, Dr.

Physician shortages disproportionately affect rural communities

Reema, who received her medical degree in psychiatry and completed three years of residency in India, had to spend three more years in residency training in Michigan after completing required exams and getting certifications in the United States. One possible solution to this issue is to recognize training from other countries for licensing and immigration purposes as long as countries have medical education systems that are similar in quality to that of the United States.

Visa Bulletin: Employment-Based Categories

Moreover, the standards are different between graduates of foreign medical schools and graduates of medical schools in the United States. One study that researched state licensing requirements from to found that states that have restricted licensing receive fewer foreign-trained doctors.

The differences among states are not just limited to residency requirements, however, as there are varying requirements for recruitment, contract terms, acceptance of subspecialties, application fees, and more. Thousands of immigrant residents live and work in rural communities, contributing to the revitalization of these communities and providing essential services.