If you are a Foreign Medical Graduate (FMG) who received your medical degree outside the US, you must complete the following four steps to practice in the US.
- ECFMG Certification
You must receive certification from the Educational Commission for Foreign Medical Graduates (ECFMG). The ECFMG assesses the readiness of international medical graduates to enter US residency or fellowship programs. The process for certification is described in the ECFMG information booklet which is available at www.ecfmg.org.
- USMLE Steps 1 & 2
Applicants for ECFMG certification must first pass Step 1 and Step 2 of the United States Medical Licensing Examination (USMLE). The USLME is the three-step examination for medical licensure in the United States. It provides a common system to evaluate candidates for medical licensure and is sponsored by the Federation of State Medical Boards of the United States (FSMB) and the National Board of Medical Examiners (NBME).
FMGs taking Steps 1 and 2 of the USMLE register with ECFMG which processes your application, determines your eligibility, and notifies you of the outcome of your application. If you apply to take the USMLE, you are required to read the USMLE Bulletin of Information on the USMLE website, www.usmle.org.
ECFMG requires that applicants pass the USMLE Steps 1 and 2 within a 7-year period. Step 2 of the USMLE has two separately administered components, the Clinical Knowledge (CK) component and the Clinical Skills (CS) component. Thus, once an applicant passes a step, they will have 7 years to complete the other steps required for ECFMG certification. To be eligible for Step 1, or Step 2, you must be a graduate of a medical school outside the US or Canada that is listed in the International Medical Education Directory (IMED).
- USMLE Step 3
To be eligible for Step 3, FMGs must have passed Steps 1 and 2 and must be certified by the ECFMG. The USMLE program recommends that for Step 3 eligibility, licensing authorities require completion, or near completion of one postgraduate training year in a program of graduate medical education accredited by the Accreditation Council for Graduate Medical Education (ACGME) or the American Osteopathic Association (AOA). Eligibility for state licensure requires that you complete Step 3 of the USMLE and to do so, you must meet the Step 3 requirements set by the state licensing authority in the state where you intend to practice medicine. FSMB serves as the registration entity for all Step 3 applicants.
For complete information on Step 3 eligibility requirements, contact the FSMB or medical licensing authority in the state in which you intend to practice. A complete list of licensing authorities is available in the USMLE Bulletin of Information.
- Residency Programs
After ECFMG certification, if you wish to become board-eligible or board certified by your specialty’s accrediting body, you must complete an accredited residency training program. You will have to complete a residency program in the US regardless of the training you have received overseas.
If you have not completed a US residency, you will not be board eligible and may be limited in your job opportunities as a result. If you have completed a residency program outside of the US, you may wish to contact your accrediting board to determine whether there is a possibility of receiving any credit for your prior training prior to completing the US-based residency program.
Working and living in the US?
As an FMG, your admission to the US is governed by a number of governmental departments and agencies, including the US Department of State (DOS www.travel.state.gov), the US Department of Labor (DOL www.dol.eta.gov), and three bureaus of the US Department of Homeland Security (DHS www.dhs.gov) – US Citizenship and Immigration Services (USCIS www.uscis.gov), Immigration and Customs Enforcement (ICE www.ice.gov), and US Customs and Border Protection (CBP www.cbp.gov).
Generally, if you are a foreign citizen, entering the US as a non-immigrant (temporary) or immigrant (Lawful Permanent Resident (LPR) or “Green Card” holder) requires several steps.
- First, you, your employer, or a relative must file a petition with the USCIS to be classified in one of the non-immigrant or immigrant visa categories. If the USCIS approves the petition, you must go to a US embassy or consulate overseas to apply for a non-immigrant or immigrant visa.
- Upon arrival at a US Port of Entry, the visa is presented to the CBP inspector who will determine whether you can be admitted to the US.
- If you are coming to the US as a non-immigrant, the inspector can authorize your admission for any length of time up to the expiration date on the visa. If you are coming to the US as an immigrant, the inspector can issue LPR or “Green Card” status. Note: Under certain circumstances, USCIS may adjust the status of a non-immigrant in the US to LPR status.
What temporary and permanent visa options are available to you as an FMG?
To be admitted to the US to participate in Graduate Medical Education (GME), you need a visa that permits employment or training. Most of the FMGs enter the US on a J-1 Exchange Visitor visa or an H-1b Specialty Occupation visa. You cannot sponsor yourself for the J-1 or H-1b visas as all work visas require program or employer sponsorship. The ECFMG sponsors FMGs for J-1 visas and employers sponsor FMGs for H and O visas.
J-1 Exchange Visitor Program
The most common visa used to participate in US GME programs is the J-1 visa. To apply for the J-1 visa, you must:
- Have passed the USMLE Step 1 and Step 2
- Have a valid ECFMG Certificate at the time of commencement of training.
- Hold a contract or an official letter of offer for a position in a program of graduate medical education or training that is affiliated with a medical school.
- Provide a statement of need from the Ministry of Health of the country of last legal permanent residence regardless of country of citizenship. This statement must provide assurance that the country needs specialists in the area in which you will receive J-1 training. It also serves to show that you intend to return home for 2 years when you finish your training.
- The ECFMG general sponsors J-1 exchange visitors for a 7-year period.
Two-Year Home Residency Requirement
If you have been admitted to the US in J-1 classification, you are obligated to return to your country of residence for two years before you will be eligible to change your status to H-1b temporary worker or obtain LPR (“Green Card”) status in the US. It is not always possible to time the receipt of a waiver with the completion of a residency program. Some FMGs make other interim arrangements while waiting for waiver processing. These include obtaining an O visa (if they can prove they have an employer sponsor and can prove that they qualify as an alien of extraordinary ability, completing a fellowship in the US in J-1 status or in Canada, or returning home pending completion of the waiver process in the US.
Waivers of the J-1 Two-Year Home Residency Requirement
There are several waivers of the two-year residency requirement which might relieve the FMG two-year home residency requirement.
- Persecution: You must demonstrate that you will suffer from persecution in your home country or country of last legal permanent residence. For example, an FMG who has been active in the political opposition to their home government and can demonstrate that they will suffer persecution on account of their political activity may qualify for a waiver.
- Hardship: You must demonstrate that fulfillment of the residency requirement would result in exceptional hardship to your US citizen or LPR spouse and/or children. For example, a physician whose US citizen spouse suffers from a rare kidney ailment that cannot be treated in the physician’s home country may qualify for a hardship waiver.
- Interested Government Agency (IGA): Sponsorship for a waiver by an IGA which is interested in the physician’s continued employment in the US Department of Health and Human Services (HHS) and the Department of Veterans Affairs (VA) are US agencies that currently sponsor FMGs for J-1 waivers. In addition, through the Conrad-30 program, state departments of public health may sponsor up to 30 J-1 primary care physicians per year for waivers to serve in Health Professional Shortage Areas (HPSAs) or Medical Underserved Areas (MUAs). Some states also sponsor sub-specialists upon showing a need in the service area. General the state departments of health administer the Conrad 30 program within each state. While all states give priority to the placement of primary care physicians (ob-gyn, psychiatry, family medicine, internal medicine, and pediatrics) some states also place subspecialists in HPSAs and MUAs. The particular policy of each state can be determined through consultation with its J-1 Conrad-30 waiver policy. States that do place sub-specialists generally have very specific requirements for sponsoring healthcare facilities. If you are considering applying for a Conrad-30 waiver, it is critical to first determine whether your potential employer will qualify as a sponsoring healthcare facility. The rules governing this process differ from state to state and it is advisable to first consult an attorney familiar with the Conrad-30 waiver process.
H-1b Specialty Occupation Visa
The H-1b visa is for temporary workers in specialty occupations who hold professional-level degrees. You may be eligible for an H-1b visa if you:
- Have passed Steps 1, 2 and 3 of the USMLE
- Have passed an English language exam.
- Hold a full, unrestricted state medical license in the state in which you will train.
- The advantage of H-1b visa is that, unlike the J-1, it does not have a two-year home residence requirement. The H-1b generally allows a foreign national to enter the US for professional level employment for up to 6 years which generally cannot be extended unless the physician remains physically present outside the US for a period not less than one year. This time limit can create problems for some residents as some residency programs are longer than 6 years, thus requiring the resident to enter J-1 status and be subject to the home residency requirement. Another advantage to an H-1b visa is that unlike the J-1 visa, there is no requirement that the FMG “intend” to return to their home country at the end of their stay in the US. This permits the FMG to complete the green card process while in H-1b classification. For example, the employer of a physician may sponsor the physician for a green card while the physician is already employed in the H-1b status. If the employer begins the green card process before the end of the physician’s 5th year in H-1b status, and the process is not completed, but remains pending at the end of the physician’s 6th year in H-1b status, the physician’s H-1b status can be extended in 1-year increments until the green card is issued or denied. A physician can self-sponsor if they can show that they are of extraordinary ability in their field or that the admission of the physician, without the need for employer sponsorship is in the national interest.
O-1 Extraordinary Ability
The O visa is available to qualified physicians even if they are ineligible for H status because they are subject to the J-1 2-year home residency requirement and have neither gone home nor received a waiver. In order to qualify for an O visa, you have to demonstrate extraordinary ability in your field. This means you have to show sustained national or international acclaim through nationally or internationally recognized awards in the specific medical field, published material about your accomplishments, original contributions of major significance, peer review, or authorship of scholarly publications. For example, if you have published scholarly articles of major significance in your specialty in prestigious medical journals, served on a panel as a judge of the work of others in your field of specialization, and have work that has been cited by others in journals or academic articles, you may qualify for O-1 visa classification. Note: this is not an exclusive list. There are several other combinations of achievement which might qualify you for O-1 status.
The O-1 visa can be helpful to FMGs in several situations. First, even if you are subject to the J-1 home residency requirement, you can still qualify for an O-1 if you have a sponsoring employer and can show extraordinary ability.
Another advantage to an O-1 visa is that, unlike the H-1b, it does not require that you have passed USMLE Steps 1, 2, and 3 or obtained an ECFMG certificate. Despite this, you are still required to meet the medical licensing requirements of the state in which you intend to practice medicine. Even if you are successful in getting O-1 status, you will be subject to J-1 home residency requirement until you go home for two years or receive a waiver.
Whether or not an O-1 visa is a good option for you depends on your personal goals. If your long-term plan is to return to your home country, this could be a good visa. If you are interested in staying in the US, this could present certain challenges in the future.
Lawful Permanent Resident (LPR) or Green Card Status
LPR status will permit you to permanently work and live in the US. After 5 years you may be eligible to apply for US citizenship. If you hold a temporary visa such as an H-1b, you are not required to apply for a green card, nor does any temporary immigration status automatically lead to green card status. If you want to apply for a green card, your employer needs to initiate the process for you on the basis of a desire to employ you on a permanent basis. How do you apply for a green card? The process generally involves 3 steps:
- Alien Labor Certification or “PERM”
This process requires your employer to demonstrate to the DOL that there is no minimally qualified US physician in the specific field who is able, willing, and available to fill the position.
- Petition for Alien worker
Once the DOL grants labor certification, your employer then files a Petition for Alien Worker with the USCIS. During this process, your employer must prove to the USCIS that it intends to hire you permanently and can pay the appropriate wage.
- Application to Adjust Status to Lawful Permanent Resident
Once the labor certification and petitioning process are complete, the government will consider your green card application. Your family members may also apply for green cards. This process, known as the adjustment of status, is primarily designed to ensure that there is nothing in your or your family members’ backgrounds that would prevent the issuance of a green card. Unless the physician is subject to a visa backlog, when there are no available immigrant visas for the physician’s country of nationality, the adjustment application may be filed together with the employer’s immigrant visa petition. For certain countries, there is over a year-long waiting period as there are more applicants than there are visas. The good news is that even if you are backlogged, you can remain in H-1b status beyond the 6-year maximum period as long as your employer has successfully completed the immigrant visa petitioning process.
Not all physicians require labor Certification
You may qualify for one of these exceptions if you meet the criteria set up by the government for any of the following.
- You are a physician of extraordinary ability.
- You are an outstanding researcher or professor.
- You are a physician of exceptional ability whose work is in the national interest.
You may be classified as a physician of “extraordinary ability” if you have demonstrated extraordinary ability in your field. Like the O-1 visa, it is awarded to a small percentage of physicians who have risen to the very top of their profession. One of its advantages is that it does not require labor certification or a job offer.
Outstanding Researchers and Professors
Your employer may sponsor you if you are an internationally recognized researcher or professor who is deemed outstanding in your academic field and you will be conducting research.
National Interest Waiver
The labor certification requirement can also be waived in the national interest if you are deemed to be an exceptionally qualified physician and your work is deemed to have intrinsic merit, be national in scope, and the national interest would be adversely affected if a labor certification were required. Physicians may also qualify for a national interest waiver of the labor certification requirement if they are willing to work in a health professional shortage area or for the VA for at least 5 years, not including any time in J-1 status.
Frequently asked questions:
- How do a find a job that can provide a J-1 visa waiver?
It is best to limit your search to facilities in Health Professional Shortage Areas and states that will support waivers for non-primary care physicians.
- If I am not board-eligible in the US, are there any job opportunities for which I might be eligible?
To practice medicine you need state licensure, not necessarily board eligibility or certifications. On the other hand, many institutions will require board eligibility or certification as a pre-requisite to a staff position for credentialing purposes.
- If I obtain an O-1 visa, who can employ me?
O-1 visas are employer-specific and therefore, O-1 visa classification may only be obtained for you by a petitioning employer. If an employer petitions on your behalf, you will already have an outstanding job offer.
- I have heard that I can get an institutional visa to work at an academic medical center without taking the USMLE. How do I apply for an institutional visa?
There is no such thing as an institutional visa. If you are not licensed, you may qualify for an H-1b visa if your job entails research only and no clinical care.
- If I am not board eligible in the US, can I cover a Level I trauma center?
This is a question of state licensing law, best answered by consulting with the appropriate state medical board.
This article is for informational purposes only and does not constitute legal advice. For legal advice for your specific situation, please consult an attorney.