Physicians

Overview. Physicians face a set of immigration requirements that apply to no other profession. Three systems operate at once and are frequently confused with one another: the immigration classification that permits a physician to be in the United States, the examination and English requirements that federal immigration law writes directly into the admissibility rules, and the licensure that a state medical board grants and that immigration law neither supplies nor substitutes for. Most difficulty in physician cases comes from decisions made early in training that close off options years later.

Licensure and immigration status are different things. Authority to practice medicine comes from the medical board of the state where the practice will occur, and each board sets its own requirements for graduates of foreign medical schools. A visa or a petition approval confers no right to practice, and a state license confers no immigration status. Both are usually necessary, they are granted by different authorities on different timetables, and neither can be assumed from the other.

The examination and English requirement in the admissibility rules. A graduate of a medical school not accredited by a body approved for the purpose by the Secretary of Education, who is coming principally to perform services as a member of the medical profession, is inadmissible unless two conditions are met: passage of parts one and two of the National Board of Medical Examiners examination, or an equivalent examination as determined by the Secretary of Health and Human Services, and competence in oral and written English, 8 U.S.C. 1182(a)(5)(B). The rule turns on the accreditation of the school and on the purpose of coming, not on nationality, and graduates of accredited schools fall outside it altogether.

Physicians are outside the health-care worker certification rule. A separate ground of inadmissibility requires health-care workers to present a credentials certificate before entering to perform labor in their field, but the statute excludes physicians from it in terms, 8 U.S.C. 1182(a)(5)(C). The screening certificate that nurses and several allied professions must obtain is therefore not part of a physician’s path, and the examination requirement described above takes its place.

Graduate medical education on the J-1 exchange visitor classification. Most foreign medical graduates enter residency or fellowship as J-1 exchange visitors, 8 U.S.C. 1101(a)(15)(J). Clinical programs of graduate medical education or training must be sponsored by the Educational Commission for Foreign Medical Graduates, 22 C.F.R. 62.27(b); an individual hospital or university cannot sponsor the clinical training itself. The regulation conditions participation on the required examinations, English competence, and a written statement of need from the government of the physician’s country of nationality or last legal permanent residence. Participation is limited to the time typically required to complete the program and, absent an exception, may not exceed seven years, 22 C.F.R. 62.27(e).

Non-clinical programs are treated differently. Where the activity is observation, consultation, teaching or research rather than patient care, a designated university or academic medical center may issue the exchange visitor document directly, 22 C.F.R. 62.27(c). The distinction between clinical and non-clinical activity runs through the whole subject and determines which requirements attach.

The J-1 two-year foreign residence requirement. Exchange visitors in three situations must return home before certain later benefits become available: those whose program was financed by a government, those whose field appears on the designated skills list for their country, and those who came in order to receive graduate medical education or training, 8 U.S.C. 1182(e). The third category catches physicians in clinical training automatically, regardless of funding or skills list. Until the requirement is satisfied or waived, the physician may not obtain an immigrant visa, permanent residence, or H or L nonimmigrant classification, and the residence must total an aggregate of at least two years in the country of nationality or last residence.

The simplest waiver route is closed to physicians. Other exchange visitors can often obtain a waiver on the strength of a written statement from their government that it has no objection. That route is expressly unavailable to a foreign medical graduate pursuing graduate medical education or training, 8 U.S.C. 1182(e) and 22 C.F.R. 41.63(a)(3). This single exclusion shapes physician planning more than any other rule in the subject.

The waiver routes that remain. Four possibilities survive: a request by an interested United States government agency, a request by a state department of public health or its equivalent, a finding that departure would impose exceptional hardship on a spouse or child who is a citizen or lawful permanent resident, and a showing that the physician would be subject to persecution on account of race, religion or political opinion, 8 U.S.C. 1182(e). Requests by a state agency, and federal agency requests on behalf of a physician who trained here, are subject to the additional conditions in 8 U.S.C. 1184(l).

What the state route demands in return. A state may sponsor no more than thirty waivers in a fiscal year, 8 U.S.C. 1184(l)(1)(B). The physician must show a bona fide offer of full-time employment at a health facility or health care organization determined to be in the public interest, must begin that employment within ninety days of receiving the waiver, and must continue for not less than three years, 8 U.S.C. 1184(l)(1)(C). The service must be in an area designated by the Secretary of Health and Human Services as having a shortage of health care professionals, with an exception for facilities under the Department of Veterans Affairs and a limited allowance for facilities serving patients from designated areas, 8 U.S.C. 1184(l)(1)(D). Failing to keep the agreement revives the two-year requirement in full, 8 U.S.C. 1184(l)(3).

The state route is not permanent legislation. The state waiver program, commonly known by the name of its sponsor, rests on a provision that applies only to physicians who acquired exchange visitor status before a date fixed by statute, a date Congress has extended repeatedly. The program has been allowed to lapse and has then been renewed, and eligibility depends on when exchange visitor status was acquired rather than on when the waiver is requested. Its availability should be confirmed at the moment a training or employment decision is made, never assumed from an earlier case.

Working in H-1B classification. A petition for a physician must show a license or other authorization required by the state of intended employment where direct patient care will be performed, and either a full and unrestricted license to practice in a foreign state or graduation from a medical school, 8 C.F.R. 214.2(h)(4)(viii)(A). The employer must then establish either that the physician is coming primarily to teach or conduct research for a public or nonprofit educational or research institution with no patient care beyond what is incidental, or that the physician has passed the licensing examination or an equivalent determined by the Secretary of Health and Human Services and is competent in English as shown by the examination given by the Educational Commission for Foreign Medical Graduates, or is a graduate of an accredited school, 8 C.F.R. 214.2(h)(4)(viii)(B). A separate exception exists for physicians of national or international renown.

The numerical cap and who escapes it. The annual limit on H-1B classification does not apply to a physician employed, or holding an offer of employment, at an institution of higher education or a related or affiliated nonprofit entity, or at a nonprofit or governmental research organization, 8 U.S.C. 1184(g)(5). Teaching hospitals and academic medical centers frequently fall within that description, which is why many physician appointments are unaffected by the annual competition. A physician who obtains a waiver of the foreign residence requirement and changes to H-1B status is likewise outside the cap, 8 U.S.C. 1184(l)(2)(A).

Permanent residence through service in an underserved area. A physician may obtain a national interest waiver of the job offer and labor certification requirements by agreeing to full-time clinical practice, treated as forty hours a week, for an aggregate of five years, not counting time spent in exchange visitor status, 8 U.S.C. 1153(b)(2)(B)(ii) and 8 C.F.R. 204.12. The service must be in a Medically Underserved Area, a Primary Medical Health Professional Shortage Area or a Mental Health Professional Shortage Area, in a specialty within the scope of the designation, or at a facility of the Department of Veterans Affairs, and a federal agency or a state department of public health must attest that the work is in the public interest. The permanent residence itself is withheld until the service is complete, so the commitment precedes the benefit. Because that undertaking runs for years and carries its own filing sequence and reporting obligations, it is treated separately: the conditions in full, the point at which the petition and the adjustment application may be filed, and the proof required while the service is being performed are set out on National Interest Waiver for Physicians.

Other permanent routes. Physicians also use the ordinary employment-based categories: a sponsored case built on labor certification, or a self-petition in a category for extraordinary ability or for outstanding professors and researchers. How the examination requirement in 8 U.S.C. 1182(a)(5)(B) interacts with those categories, and which physicians fall outside it, is the subject of the child page in this section, which addresses exemptions from the examination requirement in the permanent residence context.

Sequencing matters more than in most cases. The classification chosen for residency largely determines what follows. Training as an exchange visitor imports the foreign residence requirement and the narrow waiver routes described above; training in H-1B classification avoids that requirement but is constrained by the licensing and examination conditions and by the limits on total time in the classification. Neither choice is right in the abstract, and the decision is usually easier to make well before training begins than to repair afterward.

Related pages. Other occupation-specific topics are collected under Occupations. The temporary classifications themselves are described on Temporary Visas, the permanent residence process on Permanent Residency, and the sponsored route that most employment cases begin with on Labor Certification. Questions about a particular physician’s position may be raised through the contact page.