Jinx of the J-1 visa: IMGs finding other paths to residency

Some rural clinics are struggling to find physicians as the pool of international medical graduates willing to practice in underserved areas shrinks. The worsening situation may force some clinics to close.

By — Posted March 10, 2008

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Glenns Ferry Health Center used to attract international medical graduates looking for work. But the Idaho clinic is now struggling to hire IMGs and finds itself part of a national crisis facing rural health centers.

The clinic has one full-time physician and two locum tenens who run the center's three sites in the southern part of the state. Four doctors are needed, but two years of aggressive recruiting, including offering higher salaries, have generated no new hires, putting the clinic on the verge of closing one of its offices. That would leave patients, especially Medicaid mothers who rely on the center for prenatal and delivery services, few alternatives.

"We're staying alive with locum tenens, which is very costly, and it doesn't give patients consistency," said executive director Leslyn Phelps, RN. "If we don't recruit new physicians in the next year, we will have to cut services, including stopping our obstetrics."

Recruiting physicians for rural and urban underserved areas is always difficult. It's worse now, as the number of IMGs on J-1 visa waivers declines and more enter the country on less-restrictive temporary specialized worker H1-B visas.

The J-1 visa requires physicians to return to their home country for two years after residency. Physicians can stay if they agree to work in an underserved area for three years. Physicians on J-1 waivers are particularly important to isolated, rural clinics, which have the hardest time recruiting physicians.

Data from the Educational Commission for Foreign Medical Graduates show that the number of IMGs entering the United States on J-1 visas has dropped steadily, from 11,471 from 1996-97 to 6,033 from 2006-07. Of this group, 903 opted to stay in the U.S. in 2006, a 34% decline from 1995, when 1,374 physicians got J-1 waivers.

Rural clinics were the first to feel the pinch because they rely the most on the J-1 physician pool, officials said. According to 2004 data on federally funded health centers, 22% of physicians working at small rural clinics were fulfilling J-1 waiver obligations. Only 7% of physicians in federally funded urban clinics were J-1 physicians.

Why the change?

The J-1 visa is declining, in part, because theH1-B visa is more attractive.

Physicians with H1-B visas do not need to return home for two years, and they do not need to work in an underserved area if they stay in the U.S. The government does not track how many IMGs have H1-B visas. Practices affiliated with universities and nonprofit or government research groups are not subject to any caps on the number of H1-B visas issued.

Edward L. Langston, MD, chair of the American Medical Association Board of Trustees, said the AMA recognizes there are fewer IMGs fulfilling J-1 visa waiver obligations. "We are monitoring this situation from the needs of the IMGs and the needs of rural America," he said.

Sanjay J. Agarwal, MD, an internal medicine resident, is here on a H1-B visa and works at Hurley Medical Center in Flint, Mich. Dr. Agarwal, who trained in India, considered a residency at a university that promised strong training opportunities. But he turned it down because the university sponsored only J-1s.

"In India, everyone is aware of the difference between the J-1 and the H1-B," he said, adding that those working under a J-1 waiver are thought to be exploited and more desirable residency programs sponsor H1-B visas.

That sentiment has some evidence behind it. A series of investigative reports by the Las Vegas Sun highlighted abuses within Nevada's J-1 program, including violations of the 80-hour work week cap for residents. The newspaper also found J-1 residents working at clinics that were not in underserved areas.

The Nevada State Health Division is investigating, and has established an online complaint system.

Carl Heard, MD, chief medical officer and interim CEO for Nevada Health Centers, said that three years ago, the state hired 30 J-1 waiver physicians for underserved communities in what is called the Conrad 30 program. This year, only one J-1 waiver doctor has been hired, a sign of the shrinking supply of such doctors.

"About 10 years ago, we might get 50 to 100 unsolicited CVs from health professionals looking for opportunities to work in underserved areas," Dr. Heard said. "In the last year, we had to solicit heavily to get one to two a month."

This decline, combined with a national slide in family medicine graduates and a chronic doctor shortage in these communities, is creating a crisis.

"There are fewer family physicians coming down the pipeline," said L. Gary Hart, PhD, director of the Rural Health Office for the University of Arizona Mel and Enid Zuckerman College of Public Health in Tucson. "The J-1s help supplement that, and now that there's getting to be less J-1s, it's getting to be critical."

As a result, rural clinics face unusually high vacancy rates of 20% to 30%, Dr. Hart said.

Rhonda Hauff, primary care administrator for Yakima Neighborhood Health Services in Yakima, Wash., used to take up to six months to fill physician vacancies. But it took a year to fill the latest vacancies, one in family medicine and one in internal medicine. A recent resignation has the clinic looking for a pediatrician to add to the 11-doctor team.

"I am concerned about burn-out, for me personally and for my colleagues," said pediatrician Jocelyn Pedrosa, MD, clinic medical director. "You can never breath easy."

The intensifying physician shortage is impacting doctors and patients elsewhere.

Physicians working at Community Health Services in Fremont, Ohio, take call every third night. If one doctor is on vacation, call is every other night, according to John Imm, MD, clinic medical director. "It makes it difficult," he said. "At the end of the day, you're worn out."

He would like to add two family physicians and ease hospital call to every fifth night. But after two years of trying, the clinic has not found any new physicians.

IMGs seeking to meet service obligations tied to the J-1 visa used to fill the gap.

"I've been doing this for 16 years," said Joe Liszak, chief executive officer of Community Health Services, which has five sites in northwest Ohio and 11 full- and part-time physicians. "The last three [years] have been the worst when it comes to physician recruitment.

"I used to have a stack of resumes on my desk from J-1 doctors. By March, I'd be inundated with resumes. People would call, and I'd feel bad that we didn't have the openings.

"Right now, I'd kill to get J-1 visa candidates. I don't have one resume from a J-1. I can't find them."

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Fewer staying

The number of international medical graduates entering the United States for residencies on a J-1 visa is declining. That means fewer IMGs are seeking waivers to stay after completing their training. Physicians sponsored for J-1 waivers:

1995 2006
Federal programs 1,285 37
State programs 89 866
Total 1,374 903

Sources: U.S. Government Accountability Office, Texas Primary Care Office, Appalachian Regional Commission, Delta Regional Authority, Dept. of Health and Human Services

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Declining numbers

IMGs beginning U.S. residencies typically enter the country on J-1 or H1-B visas.

IMGs arriving
on J-1 visas
1995-96 10,901
1996-97 11,471
1997-98 10,920
1998-99 10,330
1999-00 9,400
2000-01 8,629
2001-02 8,124
2002-03 7,242
2003-04 6,592
2004-05 6,094
2005-06 5,945
2006-07 6,033

Source: Educational Commission for Foreign Medical Graduates

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Different visas

J-1 visa

Who gets it: This student visa covers international medical graduates, professors, research assistants, students, scholars and teachers participating in a training program approved by the U.S. State Dept. For IMGs, this visa is for a medical residency. The Educational Commission for Foreign Medical Graduates is the visa sponsor.

Restrictions: After completing the program, J-1 visa holders must return to their home country for two years. A medical resident who receives a waiver of this requirement must work in an underserved area for at least three years.

H1-B visa

Who gets it: This temporary work visa is awarded to professionals such as medical residents, nurses, computer analysts, engineers and scientists. The visa may be granted for up to six years.

Restrictions: A maximum of 65,000 H-1B visas are issued each year. In 2007, more than 125,000 applications were filed in one day. Employers exempt from the cap are universities, nonprofits associated with a university, and nonprofit or government research organizations. After residency, if a visa holder does not work for an employer that falls within the exemption, that person would compete for one of the 65,000 visas issued.

Sources: U.S. State Dept, ECFMG

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