Employment Strategies for Immigrant Physicians: Tips for Employers and Candidates
When it comes to staffing for health care, very few things are as intimidating as hiring foreign-born physicians. Unless, of course, it’s being the foreign-born candidate yourself. It’s not that the legal code is so difficult to comprehend. Nor is the difference in cultures the culprit, or even the interviewing process. There are guides and people to help with each of these steps and thousands have walked the path already. Indeed, no single thing makes the process overwhelming, but the gestalt of the situation gives one pause.
Nevertheless, communities need the talents of these doctors and the doctors themselves want to continue the journey they started when coming to the United States for training. How to break the logjam?
UNDERSTANDING THE OPTIONS
The first step for both employers and candidates is to gain a basic understanding of the options available to foreign-born physicians who want to work in the United States. While each situation is different and needs its own solution (best identified by a qualified attorney), these are the relevant visa options both candidates and employers should know about:
J-1 visas are used by foreign nationals who come to the United States for enrollment in medical school or other full-time education.
J-1 visas are used by foreign-born physicians (or other professionals) who attained their medical degrees in their home countries before coming to the United States to complete residency or fellowship training.
J-1 visas waivers are needed in order for foreign nationals to stay on in the United States to apply for work. Without the waiver, the candidate must return to his or her home country for two years before being eligible to come back to the United States.
J-1 visas are the most common work visas used by foreign-born physicians (and others with bachelor’s degrees or higher) who seek employment in the United States. These visas must be sponsored by employers, and the physician must be licensed as well as degreed.
Additional visas. In more extraordinary situations, O-1, TN, or E-2 visas may also be applicable to foreign-born physicians seeking work in the United States. All visas noted above are temporary work or education visas and must be renewed according to their specific criteria.
Permanent residency. Permanent residency (“Green card” status) can be gained through a number of pathways, including employment. In this circumstance, the process must be sponsored by an employer.
U.S. citizenship. A period of three or five years of permanent residency is normally required before one is eligible to apply for naturalization as a United States citizen
TIPS FOR EMPLOYERS
Employers cite a range of concerns about hiring foreign born physicians. Here are four of the most common and a word of advice from experts.
Expense. According to Ann Massey Badmus, an attorney/shareholder who specializes in immigration law with Cowles & Thompson in Dallas, TX, employers sometimes fear that sponsoring J-1 Waiver or H-1B candidates will be prohibitively expensive in terms of legal fees. While she acknowledges visa candidates cost more to hire, she notes that most attorneys handling these cases use a fixed fee. “Generally you can know what the costs would be and budget for them,” she says. Further, unless there’s something unusual about a second or third hire in this category, the company can predict that the fees will be approximately the same each time they employ a candidate on a similar visa.
Recruiting. Judy Rosman, president and CEO of Rosman Search, which specializes in placing neuroscience professionals, including neurologists, says that accepting visas is a good way to attract a broader, highly-skilled candidate pool for an open position. Although she knows some employers specifically state ‘Sorry, this is not a visa waiver opportunity’ in their advertisements when they are not in a position to support the process, she also knows of numerous employers who intentionally use the waiver opportunity as a recruiting tool.
Retention. While Rosman knows that employers may shy away from visa candidates out of concern that they will leave as soon as their visa requirements are met, she also feels that employers can take a more active role in influencing a doctor’s decision to stay in the community. For example, she describes an Iowa hospital that places an intense focus on onboarding and retention for their foreign-born physicians. “What has impressed me is that they look for connections to make for the physician in their community,” she says. “And they invite them out. I saw that first-hand. They take the doctor out with others in the community and they introduce them. They continue this for quite a long time after the doctors come on board. They know that people who have friends where they work and live are a lot less likely to leave.”
Consulting with professionals. Both Rosman and Badmus emphasize the importance of seeking assistance from legal and placement professionals to ease the process of hiring foreign-born doctors. Even with inhouse recruiters or legal counsel available, they note the value of gaining access to the broader information and reach external professionals are likely to have.
WHAT CANDIDATES NEED TO KNOW
Foreign-born job candidates may not realize how active they can and should be in the employment process. These tips provide an initial roadmap to follow.
Start early. Badmus counsels that job search and visa issues need to be addressed before the last year of a doctor’s training. “Especially for doctors of neurology who have been using H-1B visas in their training,” Badmus says. “The time limit on H-1B is six years, so assuming they’ve been in training for five years, they have very little time left before they need to be employed on a visa or permanent residency, or leave the country.” Both Badmus and Rosman also note that candidates who have started the visa process will have an edge in interviews. “Employers who haven’t had as much experience with visas are likely to be more comfortable when the candidate has already done the initial legwork,” Badmus says.
Hire an attorney. Establishing a relationship with an attorney specializing in immigration and visa issues is critical, Badmus says, both because the law is almost certainly more complex than the doctor appreciates, and because an experienced attorney will be able to identify the best pathway to meet the doctor’s goals. One mistake to avoid is the assumption that the employer’s attorney can serve the candidate’s needs. Not only will this attorney place the employer’s interests first, but he or she will not be available if the doctor changes jobs. Badmus advises candidates to ensure their attorney has the appropriate expertise, then accept that the cost of legal counsel is a continuation of the investment the doctor has already made in his or her education.
Understand the employer’s perspective. Rosman warns doctors that expressing a desire to work in a specialty that isn’t needed by the community, or describing a preference for working in a more urban setting, are mistakes that will keep the doctor from being hired. “I would never suggest somebody not do what they are interested in,” Rosman says. “But I would suggest they be realistic when they embark on their job search. If you want to do specialized fellowship training, do that. But be aware that the specialty you’re choosing might not meet the needs of most of the communities that are likely to offer you a visa waiver.” From her experience placing doctors, Rosman says the strongest pathways to employment on a visa are general neurology and any subspecialty that is part of a general inpatient/outpatient practice, such as headache, EEG, and EMG. She also notes that candidates with stroke fellowships do well in most markets.
Keep it personal. “Wherever you go, you need to envision integrating into the community in order to be happy for the long term,” Rosman says. Employers need to envision that connection as well, so Rosman advises candidates to express their enthusiasm for the work, show a warm and engaging personality, and look for ways to fit into the community for themselves and their family members. When counseling doctors with or without families, Rosman suggests they take a closer look at small communities. Even though foreign nationals are often attracted to larger cities, she has observed that smaller communities actually make it easier for families and singles to meet new people and fit in. “In a smaller community,” she says, “the physician holds a position of greater respect, and you might find that people take a greater interest in your happiness when they’re excited to have you there. I can’t tell you how many candidates I’ve had who were surprised at how much easier it was to integrate into a smaller community than they expected.”
ONE CANDIDATE’S STORY
Coming from the Philippines with his MD and an internship under his belt, Reiner See, MD, fit the profile of any number of foreign nationals pursuing professional training in United States schools. Arriving on a J-1 Visa, he took residencies and fellowships in increasingly specialized areas, from neurology to neuromuscular medicine to intraoperative neurophysiology monitoring. He also developed a relationship with a partner whose location in Boston inspired a strong desire to find employment in the area. In December 2014, he realized that goal when he accepted a dual role as a neurologist specializing in intraoperative neurophysiology monitoring at Massachusetts General Hospital and a faculty appointment in Neurology at Harvard Medical School.
The key to his success, Reiner says, was starting early in his search. “I started looking for a job in my second and third year of residency,” he says. “Knowing that J-1 jobs applicable to my preferences are very tough to find, I think the most important thing is to be patient. I knew that not being a US citizen was a big hurdle for me.”
Although he understood that he’d have better luck searching for a general neurology role in a more rural area, See decided to stay with his goal as long as possible. “I was very positive I would find a job,” he says, “but I still had many, many sleepless nights.” The most difficult part of the process, he says, was being denied for interviews based on his citizenship status. “Recruiters didn’t even want to go through the visa process. You can get denied multiple times, even though you know the employer likes you.”
See’s strategy also included a three-part backup plan. If he didn’t find an appropriate position soon enough, he planned to request an extension for his visa while he completed board exams. A second option was to consider more general neurology jobs, and his final option was to return home to the Philippines.
See knows that he was lucky to find the job he wanted, but he also knows he was strategic. His advice for other international candidates? “First, just be patient. Just keep on applying and applying and looking for the job you really want. Start early. But never sign early unless you are sure that’s the job you want. Signing a contract happens usually six or nine months before you really become available. Once you sign a contract, you cannot just suddenly change your mind. Always keep your options open.” And second? “Have a back-up option. Be honest with those who interview you: ‘I have another option that I am considering. If you help me with my visa, we can move forward.’”
Ann Massey Badmus, attorney-shareholder with Cowles & Thompson, invites doctors and employers to contact her for further information regarding legal services for immigration issues. She can be reached at firstname.lastname@example.org.
Publications: Badmus has authored two publications on immigration law: The Wise Consumer’s Guide to Hiring an Immigration Attorney (10-page pdf download) and The Immigration Prescription: The practical guide to U.S. immigration for foreign born physicians (164-page book). Both can be requested directly from Badmus at the above email.
Judy Rosman and Beth Dery of Rosman Search welcome conversations and inquiries from both employers and physician candidates, to better understand career strategies or recruitment processes from either side of the hiring desk. They can be reached at email@example.com or firstname.lastname@example.org.
Reiner See offers to advise other foreign-born doctors with questions on the job search and visa process: “To anyone who has any questions, I’d be very much willing to help. I want to share what I’ve gone through. It’s tough, but it’s not impossible.” He can be reached at rsee@mgh.Harvard.edu.