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THE VISA ISSUES
GME
in Pakistan GME in
THE UK GME in THE
USA
Basically, a visa is a permit
allowing you to enter another country, and in this discussion, this country in
question, is the United States.
If you are a non-US citizen,
then you will need to have definite, stated reason for going to the US. You will
then apply for the type of visa that reflects this stated reason. In order to
classify the types of foreign nationals on the basis of the reason they are
visiting the US, the State Department of the US issues different types of visas.
These visas are lettered from “A” all the way to “T”, with every type having
subtypes.
The A visa, for example, is for
diplomats. If you want to go to the US in your function and capacity of an
ambassador, public minister, diplomatic or consular officer, or an immediate
family member (of all these diplomatic posts), you would need to apply for the
A-1 visa.
For our purposes, there are
only four visas we need to concern ourselves with. They are the H1-B visa, J1
visa, the B1/B2 and the F1 visas. If you come across any other visa types in
your USMLE journey, you may cheerfully ignore them.
Sponsoring: A
program is said to sponsor a visa if it will take responsibility for you once
that visa is approved. This applies only to the J1 and H1-B visas.
You need to go to the US in
order to take your Step 2 CS exam as well as to attend the interviews. In order
to do this, you will need a “visiting” visa. There are two types of visiting
visas, the B1 and the B2. When you apply for these visas, your stated intention
for coming to the US is for business (in case of the B1 visa) or for pleasure
(in case of the B2 visa). You can apply to either one for the purpose of going
to the US for the Step 2 CS and/or interviews. The B visa (be it B1 or B2) is
the first visa you will need to apply for and this is where most of the visa
problems you may have heard about arise.
There are 3 types of B visas:
·
A 6-month single
entry visa – in which you’re allowed to go to the US once in a 6 month window
period
·
A 1-year double
entry visa – in which you’re allowed to go to the US twice in a 1 year window
period
·
A 5-year multiple
visa – in which you’re allowed to go come and go freely to the US within a 5
year window period.
The reason it has become
increasingly difficult for people to obtain a B visa is because of a long
history of foreigners going to the US as a temporary “visitors” and then
disappearing from the radar to stay and work illegally in the US. This has
become a huge headache for the US State Department and Department of Homeland
security, and in response, they have become increasingly suspicious of
financially poor B-visa applicants from third world countries who want to visit
the US as “tourists”. It is not surprising that the visa officers will reject
the application for a B-visa on the grounds that the individual in question is
considered a high-risk case who may not return from the
US,
but stay to work there illegally.
Therefore, for quite a number
of years now, applicants for B visas have the burden of proving to the visa
officer that they do intend to return to their country after concluding their
business in the US.
The visa officer will assume that the applicant for the B visa is going to
misuse his B visa if it is granted, and it is the responsibility (or ‘burden of
proof’) of the applicant to convince him otherwise.
This visa has, in recent years,
become the most problematic for those wishing to go to the US for the Step 2 CS
and/or interviews. It is on record that individuals who have taken both Step 1
and Step 2 CK (and scored very highly) who wish to go to the US for their
Step 2 CS/Interviews have been rejected for the B visa . Naturally, this can be
very devastating for the candidate, who by that stage has invested not only a
lot of money, but time and great effort as well. After working and planning for
years, their dream of going to the
US
for further training can be killed by a visa interview that lasts less than 5
minutes.
There are certain factors that
could help a candidate improve his chances of securing the B visas. The basic
principle behind the factors, is strong ties to the home country. If an
applicant has strong ties to his home country, it can be taken as proof that he
will most probably return to his country when his business is done, and not stay
back in the US illegally. Evidence of strong ties could include, proof of
property and/or substantial assets in the home country, immediate family in the
home country, or good socio-economic position in the home country, etc… Whatever
convinces the visa officer that you have ties to your home country that you
would not jeopardize by staying permanently (and illegally) in the
US
could improve your chances of getting the B visa.
Note that I keep on using the
words “could” or “can” when I talk about improving your chances. The reason is
that the experiences of our IMGs applying for this visa demonstrate that there
doesn’t seem to be any criteria that we can reliably use as a guide. People with
good home country ties have been rejected, while others will poor country ties
have been given the B visas. Similarly, people with great USMLE scores have been
rejected while people with less-than-good scores have been given the visa. There
is even a case of a bright young man who got 90s in both his Step 1 and Step 2
exam, went to the US on a B-visa to give his CSA exam, and came back. When the
interview season started, his B-visa had expired and he applied for another B
visa to go for this interviews but was rejected. Stories such as these have made
the whole visa issue very uncertain. Most people just leave it to fate, or God’s
will, and leave it at that.
However, I don’t wish to give
you the impression that the situation is hopeless. Far from it, many people
still get the visa. Furthermore, a lot of the people rejected for the B visa the
first time get it after the second, third or even fourth attempt. An initial
rejection for the B visa is not the end of the story. You can definitely
reapply. The only problem is that the processing for the visa can take several
months, and an initial rejection can set your whole timetable back. In many
cases, this usually means that the individual will lose the opportunity to
participate in the match that year. It is therefore highly recommended that you
apply for this visa as soon as possible in your USMLE process, so if you get
rejected the first time, you can afford the time it takes to reapply.
This is a good place to mention
Electives. As I said previously, an elective may be clinical or research. In a
research elective, you participate in a research study in a hospital or medical
university. A clinical elective involves you observing (not actually doing
anything) and studying medicine in the clinical environment of a hospital. In
recent years, it has become clear that such an elective (especially the clinical
one) helps tremendously in the whole USMLE process. For one thing, the elective
experience is, in itself, a valuable addition to your CV. Furthermore, the visa
obtained for going to such an elective is the B1 visa. Electives are offered to
medical students, not graduates. Therefore, at the time of applying for
such an elective, the individual will be enrolled in a medical college, which is
a strong proof of “ties to home country”. This is perhaps why medical students
going for electives have had a much easier time obtaining the B visa compared to
medical graduates. Now, if the visa you obtain for your elective is a is a
5-year multiple, that means it will still be valid by the time you are ready to
go to the US
to give the Step 2 CS and go for interviews. Nevertheless, it does not
automatically mean that all other visa hurdles are overcome, as we shall we in
the section on J1 visas.
The F-1 is a student visa and
when granted, allows you to join a university or college in the US to pursue a
certain degree. It is easier to get an F-1 visa approved than a B-1 visa.
Therefore what we have seen happening in recent years (particularly in India),
is doctors with visa problems applying to colleges/universities in the US to
study for the one year Master of Public Health (MPH) degree. This MPH degree not
only enhances an IMG’s credentials, but also allows the IMG to travel to the US.
While the visa problem may be bypassed, the disadvantage of going by this route
is the cost involved. Depending on the college/university, a one-year masters
degree can cost anywhere from $5,000 to $40,000. Furthermore, if a doctor has
yet to give his USMLE Steps, then it will become very difficult for him to study
for both his MPH degree and his Steps.
An alternative to applying for
the F-1 on the basis of an MPH degree in a college/university is the Kaplan
USMLE courses. These courses vary in duration with the longest lasting a year.
If you enroll in a Kaplan USMLE course, you will be eligible to apply for the
F-1 visa. A further, obvious advantage is that attending the Kaplan course mean
you’ll be studying for the Steps. The downside is that the one-year course costs
approximately $10,000. Along with the cost of the course will be the living
expenses you’ll have to bear during your stay there.
In order to take the Step 2 CS
exam, you need a B1/B2 visiting visa to travel to the US where this exam is
conducted. These days, the key to getting a visiting visa is to provide
demonstrable proof that you have business in the US you need to attend to. If
you apply for the Step 2 CS exam, you will be mailed the registration receipt
for the exam, and this will suffice for the “proof” needed.
Currently, most candidates
apply for the Step 2 CS exam after their Step 2 CK. This was usually around
February or March of the year they were applying to ERAS. The problem with this
is that these days, visa processing and approval can take up to 6 months and if
you’re unlucky sometimes even longer. Therefore, a candidate applying in
February/March for a visiting visa was at risk of getting it approved at a time
when the interview season is over – causing him to miss his chance at a match
that year.
Since the Step 2 CS exam can
now be given even by medical students, the logical thing to do is to apply for a
visiting visa very early on in the USMLE process. Suppose, you apply for the
visiting visa in January 2006, around the time you start studying for the Step
1. In that case, even if your visa application process takes up to a year, it
will still come through in January 2007. Thereafter you can travel to the US
when it is convenient for you, without having to worry about missing interview
dates – which are still 9 months away.
Applying very early for a
visiting visa also gives you the opportunity to reapply if your application is
rejected the first time (as it often is) and not miss your target Match year.
Often people who were rejected the first, or even second time got approved in
their third try.
To illustrate:
suppose you’re aiming to participate in the 2008 Match. Let’s also assume the
visa processing time takes 6 months. If you apply in January 2006 and get
rejected the first time in June 2006, you will reapply immediately that same
month. If your application gets rejected a second time in December 2006, you
will immediately reapply yet again. If you’re lucky, you’ll get approved the
third time and be allowed to go to the US somewhere in the middle of 2007, where
you’ll be right on time to take the Step 2 CS, Step 3 and attend your
interviews.
Visiting visas are granted to
medical students more readily than medical graduates so the best time to apply
might be in your final year of medical college/university.
If you obtain a 5-year multiple
visa while still a student, you don’t have to worry any further about visa
problems when the time to take the interviews and Step 3 arrives, about two
years later.
On the other hand, let’s
suppose as a final year student, you get only a 6-month or 1-year entry visa
(and avail it to go to the
US
to take and pass the Step 2 CS). Such a visa would expire by the time you were
ready to go for interviews and Step 3. In that case, after passing first the
Step 2 CS, then Step 1 and Step 2 CK, you should immediately apply for your
ECFMG certification and register for the Step 3 exam and apply for a visiting
visa on the basis of your Step 3 registration receipt. It is hoped that having
already previously received a visiting visa (even if was just a 6-month or
1-year duration), the chances of you getting a visa a second time to take your
Step 3 and go for interviews will be good (although this may not always be the
case). Even if this second visa is only a 6-month entry visa, it would be
adequate to go to the US to take the Step 3 and attend interviews.
The H1-B visa is given to
“Specialty Occupations, DOD workers, and fashion models”.
Plainly put, the H1-B is a work
visa. It allows you to enter the US and use your professional credentials to
earn a living. In order to do so, you need to secure an employment first, and in
our case, the employer will be a hospital program where the doctor will also be
trained. This also explains why IMGs who wish to be considered for a H1-B visa
have to pass the Step 3 first. The Step 3 is evidence of your ability to
practice medicine in an unsupervised setting. Before the program hires you, it
wants proof you can do the job. Not all programs sponsor IMGs for H1-B visas so
if you’re interested in getting an H1-B visa, you have to do your research and
find out which ones do. In general community-based hospitals are more likely to
sponsor H1-B than university-based hospitals but there are many exceptions.
The H1-B visa is widely
preferred by IMGs for the reason that it allows the IMG to file an application
for a Green Card (a permanent residence status) in the US. In order to apply for
a Green Card, your employer has to sponsor you for one. The number of residency
programs that sponsor their H1-B workers for a green card is small, the reason
being that the residency is a “training” position rather than an “employment”
one.
The H1-B is valid for 6 years.
This allows IMGs on H1-B visas to apply for a job after their 3-year residency
is over with another employer who will sponsor a green card for them.
Since by the time you complete a residency, you’ll be a well-qualified doctor,
getting jobs in such places is not too difficult.
There are other clear
advantages of the H1-B over the J1. Firstly, residents on the J1 visa
have to overcome the hurdle of the “two year requirement” (see below) which is
something H1-B residents have to worry about. Secondly, residents working
on the H1-B visa can travel back to their own country (for vacations or
whatever) freely, without having to renew this visa when returning to the US. By
contrast, residents with the J1 visa who visit their country have to renew the
J1 visa when they are returning to the
US.
There is always the possibility of the J1 renewal being rejected - it has
happened. As a result, the J1 holders find themselves a less secure than the
H1-B holders. Thirdly, once an application for an H1-B visa is made by
the employer, it is almost never rejected by the American Embassy. The H1-B visa
is issued with the presumption that the H1-B worker is filling a vital skilled
worker gap for which an American worker of similar credentials cannot be found.
Therefore, it is in the interest of the US to issue such a visa when an employer
in the US
asks for it. By contrast, the concept of the J1 visa, as we shall see, carries
no particular influence on US interests, and as such can (and has been)
rejected.
The H1-B visa is applied for by
your employer, not by you. When you been matched with a program that will
sponsor you for a H1-B visa, it is up to them to apply for the H1-B visa on your
behalf. In order to be eligible for H1-B sponsorship, you need to have your Step
3 result (passed, of course), no later than (and sooner if possible), March of
the year the residency starts. This is important to ensure that the H1-B visa
application has sufficient time to get processed before the residency actually
begins. It can take as long as 6 months to process. However, a service called
premium processing is in place which guarantees that your H1-B
application will be processed in under 2 weeks for a fee of $1000 dollars. If
you find a program that sponsors you for an H1-B visa, and the application is
processed and approved in time, then you can go and join the program as a
resident on the first of July of that year.
In 1961, the US Congress passed
an act called the “Mutual Educational and Cultural Exchange Act.” According to
the US State Department: “The purpose of the Act is to increase mutual
understanding between the people of the
United States and the people of other countries by means of educational and cultural
exchanges. International educational and cultural exchanges are one of the most
effective means of developing lasting and meaningful relationships. They provide
an extremely valuable opportunity to experience the
United States and our way of life. Foreign nationals come to the
United States to participate in a wide variety of educational and cultural exchange
programs.”
In order to come to the US for
the purpose of “participating in educational and cultural exchange programs,”
the J1 visa was created. Certain institutions were given the right to sponsor J1
visas. Of the many such institutions, many training hospitals were also
included.
A person coming into the US on
a J1 visa would be an “exchange visitor”, i.e., he has come to acquire
skills in the US that he will take back with him to his own country once the
period of training is over.
The underlying principle of the
exchange program is that the US allows third world countries to benefit from
Western expertise by allowing them to send professionals to be trained further
for a fixed period of time. When this time is over, the professional will go
back to his home country to share and spread the skills he has acquired. If this
principle were actually applied, it would benefit the home country immensely,
because every year we would have hundreds, if not thousands of highly trained
doctors coming back to their country instead of going out.
In order to ensure that the
exchange visitors actually do go back home after the training is over, the J1
holder is subject to a Two-Year Foreign Residency Requirement. This requirement
insists that the J1 holder return to his home country for at least two years
after the period of training is over unless he receives an exemption for
this requirement. If the J1 is seen by most IMGs as undesirable, it is mostly
because they don’t wish to face the prospect of being forced to return to their
own countries.
The most common way the
exemption to the 2-year requirement is met is to be employed in a medically
underserved area in the
US.
What scares most doctors who try to exempt themselves from the 2-year
requirement is that these “underserved” areas may be in the middle of nowhere.
After all, the area would be medically underserved for a reason – few doctors
want to practice there. Furthermore, you may not get the appointment to an
underserved area in the first place, and if that happens to be the case, you
will have no choice but to leave. The exemption from the 2-year requirement
therefore is a huge source of worry for many doctors on the J-1 visa when the
time to deal with this problem draws near.
When you are matched with a
program that sponsors the J1 visa, they will send you a letter of appointment.
You will apply for a J1 visa at the American Embassy on the strength of this
letter of appointment. Remember, the match occurs on the 3rd Wednesday of every
March and the residency starts on the 1st of July, which is 3 and a half months
away. A potentially serious problem arises here: three and a half months may not
be enough time to process the J1 visa application. There is no premium
processing system in place for the J1. Such an application can take as long as 6
months. Therefore, if it takes more than 3 and a half months, you’ll miss the
start of your residency.
This in fact is precisely what
has been happening in the last few years. Many applicants, armed with a letter
of appointment sponsoring a J1 visa have gone to the US Embassy only to find
themselves months later in no-man’s-land their residency start date has come and
gone while their J1 application is still pending. Whether the candidate lost the
residency over this depended on the generosity of the program itself, but as can
be expected, the increased trend of prolonged J1 processing time has tried the
patience of many programs. The program suffers greatly itself, because it has to
redistribute the existing workload on its already overworked resident
population. This has led to a disturbing trend in that programs with bad
J1-processing experiences have stopped accepting graduates from countries (like
Pakistan) where potentially prolonged clearance of the J1 visas meant a
possibility of missing the start of the residency. The program directors cannot
be blamed for treating Pakistani applicants with some caution. Their primary
responsibility is to their program, and they must do what is best for the
program. If this means accepting less “high-risk” doctors into their program,
then so be it.
The delayed processing time of
the J1 visa for some doctors is not the only problem to arise in the last few
years. It appears that the J1 visa has been out-rightly rejected by the American
Embassy. This perhaps is the most devastating blow of all. The very last hurdle
is the J1 visa. After all the Step exams, all the interviews, all the hard work,
money and time invested, the very last thing an IMG requires is for his J1 to be
approved so he can go work in the US. It is not known how many doctors have
faced such a predicament, but its rising incidence has prompted the Association
of Pakistani Physicians of North America (APPNA) to write a petition to the US
State Department in July of 2003 (when residencies started and the J1 visa
status was apparent). The subject of the petition was “Significant Rise In The
J1 Visa Refusals To Pakistani Phycisians”. The petition mentioned the following,
among other, points:
·
In the previous
month of June 2003, there has been a significant rise in the refusal of J1
trainee visas to Pakistani physicians. These physicians have completed an
exhaustive process of taking the required qualifying tests, have received ECFMG
(Education Commission on Foreign Medical Graduates) certification, were
interviewed and selected in a US Residency Program in an accredited training
hospital, were issued the contracts by the hospital and had received the
necessary paperwork from the ECFMG and the Pakistani Government for an Exchange
Visa Program. The final step was to get a J1 visa from the US Embassy in
Islamabad
to proceed to USA for training. Traditionally the residency-training year starts
on July 1st of every year.
·
We know of at
least twenty-five such physicians who were turned down at the eleventh hour.
There are probably many more.
·
The reasons given
to the visa applicants, through the information received by us, were varied, but
universally flawed. Reasons ranged from unsubstantiated technical reasons, to
"USA does not need any more doctors", to not enough social ties for the
individual to come back to Pakistan. It is to be noted that the J1 visa is
issued specifically for the purpose of returning to the country of origin.
·
We strongly
believe that all the reasons given (for rejecting the J1 visas) are trivial at
best and give the impression of a concerted policy to deny visas to aspiring
physicians from Pakistan. We believe that the policies are not enforced with
same level of strictness to physicians from countries other than
Pakistan.
As such they are discriminatory.
·
(This) will also
deter the future training program directors to select physicians from
Pakistan as
they may again face similar denials of visas.
At the time of writing this
manual, the direction of this trend is unclear. It will be evident from the
Match of 2005 whether the situation has worsened or improved since it was first
noticed in 2003. | 
