Upcoming Match spotlights visa woes facing residency programs

Late arrivals and no-shows bring fresh anxiety to this year's Match.

By Myrle Croasdale — Posted March 8, 2004

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As a first-year psychiatry resident, Aftab Khan, MD, should be busy learning psychotherapy and psychopharmacology. Instead, he's making repeated visits to the U.S. consulate in Hyderabad, India, pleading to be allowed to return to the United States.

He left West Virginia University in Charleston in early February to get married in India. He was supposed to be gone two weeks. He has a valid visa, but he's caught in a bureaucratic snafu that is threatening his visa status.

"He's pretty sad," said Thomas Dickey III, MD, Dr. Kahn's program director. "He said in an e-mail, 'One day I'm a resident about to get married; the next I feel like a nobody.' "

This is the latest in a year of visa woes for Dr. Dickey. Only two out of his five first-year residents started July 1. Of the three with visa issues, one was delayed until Aug. 1, the second until the third week of September and the third denied a visa altogether. Dr. Dickey waited until October, then started looking for someone else. The replacement started Jan. 1, but Dr. Khan's problem has thrown the program right back into the cycle of uncertainty.

"You can imagine how disruptive this is," Dr. Dickey said.

International medical graduates make up one-quarter of the resident work force, and problems such as Dr. Dickey's have plagued residencies across the country following implementation of heightened security measures by the Dept. of Homeland Security.

Match day jitters

Now, with the National Resident Matching Program's Match day looming, residency directors are edgy. Many can't fill their programs without IMGs, yet hiring physicians who need visas has become risky business.

"It's not made us absolutely gun-shy," Dr. Dickey said. "We've ranked several candidates for the upcoming Match who will need J-1 visas."

But he's betting that programs will give preference to permanent residents and U.S. citizens. "My guess is that this is bound to influence some program directors," he said.

According to Mona Signer, the director of the NRMP, that's already happening.

She said an NRMP survey this fall revealed that some resident directors had upped the number of residents they are hiring outside the match process. After an increased number of delays in 2003, they want to get a jump start on the visa application process this year.

In internal medicine, which is particularly dependent on IMGs, 40% of the 388 programs made this choice, she said.

"It appears this is a greater problem for internal medicine than for other specialties," Signer said. "Clearly, those programs that have IMGs are having an issue."

Pakistani physicians hard hit

Raana Akbar, MD, president of the Assn. of Pakistani Physicians of North America, said the change in political climate has been particularly punitive for physicians from Pakistan.

Dr. Akbar has been contacted by numerous physicians who have been denied entry into the United States. Some were trying to come in to take the Clinical Skills Assessment test, which IMGs are required to pass before participating in the Match. Others were denied visas to the United States after landing residencies here.

"The present situation creates a crisis for the affected U.S. hospitals," Dr. Akbar said. "Training program directors after this experience are less likely to select physicians from Pakistan."

Dr. Akbar said that of 154 Pakistani physicians seeking J-1 visas for first-year residency positions in 2003, only 40 arrived on time, 12 were one to 14 days late, 24 came within 30 days, and 42 were more than a month late. The remaining 36 had not arrived as of Sept. 22, 2003.

"No other country had 42 residents who were more than a month late," she said, citing data from the Educational Commission for Foreign Medical Graduates. "At least 66 arrived due to our direct pressure. If we'd not done this, they wouldn't be here at all."

The ECFMG said it sponsored 1,133 physicians for J-1 visas for their first year of training in 2003. As of Jan. 6, 2004, 1,048 were here, with 924 arriving on time or within 31 days of their program start date.

The numbers suggest that 85 physicians were delayed more than 31 days or were not able to enter the United States at all. And while that seems like a drop in the bucket out of the 18,806 first-year positions filled in 2003, each absent physician means that program directors have to juggle work schedules and eventually decide whether to hire another resident.

Unknown is the number of residents, like Dr. Khan, who were in the midst of their training when they were delayed or prohibited from returning after traveling outside of the country.

Charles Brooks, MD, housestaff program director for internal medicine at the University of Missouri, Columbia, said one way his program has dealt with delays is to make the July 1 start date part of the contract. He tells residents they'll be out of a job if they don't start July 1, and he'll find a replacement.

"We can't afford to be short," Dr. Brooks said. "You don't know if it will be one month or six months."

The program always has hired a large number of IMGs, with the attendant inevitable visa hassles, but 2003 stood out. For the first time in Dr. Brooks' memory, one resident was denied a visa. Dr. Brooks bent the rules by holding open his slot, but the Pakistani doctor was not allowed into the country.

Adding to the overall edginess is confusion over changes to the H-1B visa, which allows people in technical and medical professions to work in the United States for up to six years. They also may apply for permanent residency without leaving the country. While 195,000 H-1Bs used to be available each year, that number has now been capped at 65,000. That quota was filled Feb. 17.

Residencies affiliated with an institution of higher education, government research organization or nonprofit research group are exempt from this cap, but it's unclear how many programs that includes.

Todd Dickinson, assistant director of public policy at the Assn. of Program Directors in Internal Medicine, said most programs have some level of affiliation with a university, but there were no data on how many qualify for this exemption or have claimed it in the past.

Meanwhile, concern about visas is so high that some doctors are taking jobs before their training is complete.

Ross Hill, MD, associate professor in pulmonary/critical care medicine at State University of New York Downstate Medical Center, Brooklyn, said one of his fellows was offered a job waiving the requirement attached to his J-1 that he return home for two years before applying for another visa. The physician left six months early to take it.

"There's tremendous pressure to retain visa status since there's a sense that visas are very difficult to get now," Dr. Hill said. "The repercussions for the program, including other trainees, are considerable."

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Getting in

About one-quarter of the country's 98,000 residents are international medical graduates. Although some of these IMGs are U.S. citizens or permanent residents, a significant number must get a visa, usually an H-1B or a J-1, to train in this country.

Number Percent
Native U.S. citizen 3,257 12.6%
Naturalized U.S. citizen 2,578 10.0%
Permanent resident 6,682 25.9%
B-1, B-2 temporary visitor 70 0.3%
F-1 student 56 0.2%
H-1, H-1B, H-2, H-3 temporary worker 1,619 6.3%
J-1, J-2 exchange visitor 4,798 18.6%
Refugee/asylee/ displaced person 55 0.2%
Other 375 1.5%
Unknown 6,293 24.4%
Total 25,783 100.0%

Source: Journal of the American Medical Association, Sept. 3, 2003. Data are from the 2002 National GME Census, the most current available.

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Prepping for the match

The number of IMGs taking the Clinical Skills Assessment, a prerequisite for participating in the National Resident Matching Program, has risen steadily over the past five years. About 7% of those who registered to take this test in 2003 contacted the Educational Commission for Foreign Medical Graduates regarding problems getting visas.

CSA tests
given to IMGs
Portion given to
non-U.S. citizens
2004 Match 11,500 83.1%
2003 Match 9,000 75.0%
2002 Match 7,000 75.0%
2001 Match 6,000 77.0%
2000 Match 6,000 72.9%

Source: Educational Commission for Foreign Medical Graduates

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