By Robert D. Aronson, Immigration Attorney, Fredrikson and Byron, PA
Years ago, physician recruiters would have had little need to understand immigration matters, much less work immigration into an effective recruitment program. But we have witnessed a major shortage in the physician workforce, which has challenged some of the fundamental tenets of healthcare coverage, including the need to tap into non-traditional provider sources of physicians, such as International Medical Graduates (IMGs).
Over these past years, we have seen a number of major developments that underscore the need of recruiters to gain an understanding of IMG immigration, including: (1) our immigration laws create some significant inducements for IMGs to take up positions in medically-underserved areas and other hard-to-fill placements; (2) communities have grown increasingly receptive to accepting IMGs; (3) statistically, IMGs exhibit the same level of professional competence as their US counterparts; and (4) there is a pronounced and growing shortage in the domestic physician workforce that combined with geographical maldistribution patterns creates major recruitment challenges.
As a result of these factors and the inherent desire of IMGs to find not only a satisfying, challenging position but also immigration stability, physician recruiters have a major opportunity to place superbly qualified IMGs in medically underserved communities and hard-to-fill positions.
Particularly given the pervasive physician shortage, it is frankly not enough for recruiters to simply understand the basics of IMG immigration. Rather, it is imperative for recruiters to make their health care systems receptive to IMGs, and thus make immigration into a competitive recruitment edge. This article, therefore, presents 10 points intended not only to widen the pool of physician candidates, but to enhance physician recruiters’ effectiveness by making immigration into a powerful tool to attract and retain international physicians.
1. Assess your system’s needs
Our immigration laws contain certain very promotive provisions—particularly, the Conrad State 30 Waiver program and the National Interest Waiver provisions—that facilitate the placement of IMGs in medically-underserved areas. Within some states, it is even possible to gain J-1 waivers based on non-medically underserved placements, provided that your system has a strong track record as a safety net provider. In short, assess both the geographic locations of your open placements and your own system’s commitment to serving the indigent and medically-underserved.
2. Dialogue with the state of intended placement
Particularly in J-1 recruitments, the J-1 waiver officer in the state of intended placement holds significant discretion in recommending J-1 waivers. Most waiver officials working within the departments of health are quite open to dialogue with employers to discuss waiver possibilities and understanding the merits of J-1 waiver cases.
3. Timing the decision to hire
Each state is granted 30 J-1 waiver numbers that become available each October 1. It is important to have some understanding of the pace at which J-1 waivers are normally utilized in the state of intended practice, as this will influence significantly your key decision dates on finalizing an employment offer with an IMG candidate. While the common wisdom is that J-1 waivers should be filed on or shortly after October 1 while the full complement of waiver numbers remain in existence, some states traditionally have unused waiver numbers lasting well into the fiscal year.
4. Are there other waiver sources?
Even if a state has used up its full complement of Conrad waivers, there may be alternative waiver possibilities through other federal agencies, such as the Department of Health and Human Services or various other regional waiver sponsors. In the alternative, certain physicians face hardship or persecution in their home countries of such magnitude as to enable them in their own right to apply for waivers. Thus, it is important to explore the full range of waiver possibilities.
5. Role of your immigration attorney
You have every right to expect your immigration attorney not only to provide superb legal advice, but also to become part of your active recruitment team. As you assess candidates, bring your immigration attorney into the decision-making process, particularly by authorizing your attorney to speak with your IMG candidates. Not only can such a conversation be useful in pre-qualifying a case for a successful immigration outcome, but the involvement of your attorney communicates quite powerfully to the candidate your seriousness and commitment in addressing your candidate’s immigration needs.
6. Dealing with quotas
Many immigration cases, particularly in instances of H-1B recruitment and also the permanent resident process, are plagued with substantial backlogs in the quota system. Private, for profit employers face particular challenges when recruiting H-1B physicians owing to the H-1B cap (or quota), but it may be possible to circumvent these restrictions by entering into collaborative relationships with academic institutions or teaching hospitals.
7. IMGs from India
India is the largest single provider country of IMGs in the United States. Regrettably, India faces long backlogs in its quota lines for permanent residence. From the recruiter’s standpoint, this is a mixed blessing. On the one hand, Indian IMGs oftentimes make the prompt commencement of permanent residence a condition for offer acceptance; on the other hand, the long backlogs result in a very desirable consequence of building in a lengthy retention component to the physician’s employment.
8. Spousal needs
One of the unfortunate aspects of US immigration is that all too often, a dependent’s spouse does not have employment authorization, thereby creating a substantial disparity of satisfaction between the working IMG and his/her dependent spouse. This situation is particularly concerning in rural or isolated communities. But there are certainly ways to better integrate a dependent’s spouse into the community, including certain proactive measures to provide employment authorization or other benefits that would enhance the spouse’s personal satisfaction.
9. Creating a long-term immigration/professional development plan
The J-1 waiver process builds in a three-year retention period that requires the IMG to work specifically for the sponsoring employer. But it is oftentimes possible to leverage this initial three-year commitment period into a much longer, ongoing commitment. Our immigration system has generally recognized the physician shortage situation by enabling employers to successfully sponsor IMGs for permanent residence. In short, don’t be afraid to commit to the sponsorship of an IMG for permanent residence; the law is somewhat on your side.
10. Establishing transparent immigration policies
There is a significant benefit for health care systems to have established immigration policies, particularly relating to the factors and timeline for commencing a case for permanent resident status. Many IMGs will base their employment decisions on their realistic prospects to achieve permanent resident status. A system that has an established track record of successfully navigating the permanent resident process and doing it in a fair, equitable manner will have significant advantages in their recruitment and retention of IMGs.
As with any recruitment, a physician recruiter has to understand the motivating factors guiding the decisions of the physician candidate. In most cases, IMGs have two main objectives: (1) to obtain a good, stimulating employment position; and (2) to attain immigration status, ultimately permanent residence. As a recruiter, you can substantially enhance your competitive advantage when recruiting IMGs by highlighting your own conversancy with US immigration matters and your system’s commitment to successful immigration outcomes. In short, rather than begrudgingly dealing with our immigration system, recruiters might consider highlighting their immigration capabilities and successes as forthrightly as possible.