International medical graduate information

An international medical graduate in the U.S. is a physician who has graduated medical school from outside of the U.S. or Canada. They comprise about 25% of the U.S. physician workforce.

An IMG may be a U.S. citizen or permanent resident (a “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.

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.

ERAS 

AAMC 

The National Resident Matching Program® (NRMP®) is a nonprofit 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.

NRMP 

Main Residency Match 

Medicine and Pediatric Specialties Match

The Educational Commission for Foreign Medical Graduates 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.

ECFMG 

The Accreditation Council for Graduate Medical Education sets and monitors compliance with standards for internship, residency and fellowship programs across all medical specialties in the U.S. They accredit programs and ensure the education program meets standards. 

ACGME 

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

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

ABIM 

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.

FSMB 

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.

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. In 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 that accepts waiver requests in facilities located in Virginia, North Carolina, South Carolina, Georgia, Alabama, Mississippi and all of Florida.
5. The U.S. 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 U.S. 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 U.S. 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

• US/Canadian/ACGME-I Residency pathway- Candidates are eligible for this pathway if they have completed internal medicine training in an ACGME-accredited residency program, an AOA-approved residency program, a program with ACGME International (ACGME-I) Advanced Specialty Accreditation, or a Royal College of Physicians and Surgeons of Canada (RCPSC)-accredited or College of Family Physicians of Canada (CFPC)-accredited residency program located in Canada.
  • For additional details, please see the ACGME Infectious Diseases Common Program Requirements (see section III).  

    ACGME 

  • Note that as of the drafting of this document, ABIM may not recognize ACGME-I training for board certification. 
• Exceptional candidate pathway
  • IMGs who have completed internal medicine training abroad may qualify for a fellowship as an “exceptional candidate.”

Per 3.2b. of the ACGME Infectious Diseases Program Requirements (and the corresponding section of the nephrology Program Requirements) the proposed candidate must have:

Beyond this guidance, the assessment of a candidate’s qualifications are determined by the local GMEC.

Program Directors should discuss with their GME Office/DIO as to whether these requirements can be satisfied within the time constraints of The Match.

Individual institutions may impose additional requirements on trainees beyond those laid out by ACGME or licensing boards. Please check with your GME office for any policies governing trainee qualifications.

For example, Hospital A may require that all fellows entering have passed USMLE Step 3 prior to matriculation, whereas the local medical board only requires USMLE Steps 1 and 2CK to issue a training license.

• J-1, Exchange Visitor
• J-2 EAD (Dependent of a J-1 visa recipient with work authorization)
• ​H1-B Specialty Occupations
• ​H-4 EAD (dependent visa with work authorization)
• EB-1 (Employment based)
• ​O visas, Individuals with extraordinary ability or achievement (Note: spouse/dependents of O-visa holders are not authorized to work in the United States)

​See Table 1 for brief comparison of J-1 and H-1B visas.

Other: In uncommon circumstances, a candidate may be eligible for employment under a different visa based on spouse employment status or bilateral treaties with other nations.  Legal consultation is advised in these circumstances.

Costs of the H-1B visa are borne by the employer, whereas costs of the J-1 visa are borne by the trainee.  Costs of an H-1B visa are at minimum $460 filing fee, $500 anti-fraud fee, and optional $2805 premium processing fee.  The visa candidate may volunteer to pay consular and premium processing fees. Other fees may apply depending on the employer sponsoring the visa.  Attorney fees and any local processing fees levied by your institution are in addition to these filing fees.

The ECFMG is the body designated to sponsor physicians through the Exchange Visitor Sponsorship Program.  Programs will need to need to work with their Designated Institution Official (DIO) to submit required sponsorship paperwork, including a program description in the format found here:

https://ecfmg.org/evsp/resources.html
https://ecfmg.org/evsp/evspgfpd.pdf

​The program director is responsible for signing off on verifications required by the Department of State.

Candidates for subspecialty certification must be board certified in the parent specialty to be board eligible for the subspecialty.

For those who have not completed an ACGME-accredited residency, some alternative pathways are outlined below. Note that at the time this document is being drafted, ACGME-I accredited residencies are not delineated as an option by ABIM for board eligibility.

View ABIM board eligibility requirements 

• A candidate may be granted credit in lieu of training. The ABIM policies and procedures linked above outline how to obtain up to 12 months of credit. This time is not granted automatically, and a Program Director must petition the Board to obtain credit.

• Candidate for special consideration

• • Candidates for this pathway will have:
    • Completed three or more years of verified graduate medical education training in internal medicine and/or a subspecialty abroad.
    • Certification in Internal Medicine from ABIM for certification in a subspecialty.
    • An academic rank of Assistant Professor or higher.
    • A full-time faculty appointment for a minimum of three (3) immediately prior and consecutive years at the same institution.
    • Full-time faculty members are those who supervise and teach trainees (students, residents or fellows) in clinical settings that include direct patient care.
    • The appointment must be at an LCME- or Canadian-accredited medical school or at an ACGME- or Canadian-accredited internal medicine residency or subspecialty fellowship training program.
    • A valid, unrestricted, and unchallenged medical license to practice medicine in the United States, its territories, or Canada.

Funds from the NIH and certain other federal grants may be used to support only eligible U.S. citizens or permanent residents, regardless of whether they are an IMG. If your fellowship relies on these grants to support part or all of the fellowship, you will need to find alternative funding mechanisms for IMGs.

Either track is permissible with certain provisions.

It is permissible to accept an applicant into a 3 year fellowship track with a research component if this is prespecified in the program description when applying for the initial visa.  Extending a fellowship from a 2 year to a 3 year fellowship for the purposes of research only is not permitted by the Department of State.  Thus, it is best that funding be secured prior to accepting a fellow on a J-1 visa into a track with a research year. A fellow may, however, enroll in a subsequent clinical training program if they are not time-bound by their J-1 visa.  

Please see https://www.ecfmg.org/evsp/applying-types.html for details.

In addition, the program should consider funding sources.  Some traditional sources of funding for fellows in a research year such as NIH funded training grants may not be used for trainees who are not U.S. Citizens or Permanent Residents.  Foundation or professional society grants may be an option.