Do you need to consider H1B vs J1 visa while ranking program?

Immigration status is a very important issue for Resident Physicians. Here we have presented basics of H1B and J1 visa based upon our experiences.

H1B Visa is also known as work visa. To obtain H1B visa, you need to have completed step 3 and your program must be willing to sponsor you. Most of the hospital systems are non-profit so once your hospital sponsors you H1B visa you will most likely get it.

Travel: Once your H1B visa is approved many people have it stamped on their passport from US Embassy in their home country. Once you have valid H1B visa you can travel in and out of US as many times as you want.

Spouse: Spouse of H1B visa will be eligible for H4 visa but they usually cannot work on this status. (There are few recent changes with H4 visa work permit, please confirm with your hospital attorney.)

Pathway to Permanent Residency/ Green Card: Once you complete residency you can apply for work with any organization that will sponsor you a new H1B visa and you will be eligible to apply for Green Card. 

Pathway to fellowship: You could go for fellowship on H1B visa but you have restriction to programs that offer H1B visa if you want to maintain your H1B status. Or you could as well change your status to J1 visa for fellowship. Or you may want to wait till you have permanent residency before going into fellowship.

J1 Visa is also known as exchange visitor visa. You need approval from Ministry of Health in Nepal and obtain a statement of need. ECFMG sponsors J1 visa and the programs who take IMGs support it. If you match in a program that offers H1B visa but you do not have enough time to process H1B or do not meet requirement for H1B like completion of step 3, you may still be able to get J1 visa. Once you get your J1 visa approved you will need to go to US Embassy in Nepal to get it stamped.

Travel:  Although your DS 2019 is approved for three years US embassy usually gives J1 visa for one year. You can easily extend your J1 visa while in US without having to travel to Nepal yearly for extension. However if you travel back to Nepal after your visa has expired, you will have to go to US Embassy and get it stamped prior to returning to US.

Spouse: Spouse of J1 will be eligible for J2 visa and will be able to work after obtaining work permit.

Pathway to Permanent Residency/ Green Card: Once you complete residency you can apply for work with hospitals that qualify for J1 waiver. Most of them are located in rural or under-served areas. There are 30 spots for Conrad J1 waiver in each state. States like New York, New Jersey are competitive and many states offer waiver positions to primary care than specialist. You need to work for three years to meet waiver requirement. You should start looking for job by middle of the second year of your residency if you are particular about the area you want to live and work. You will be eligible to apply for Green Card only after completion of J1 waiver. 

Pathway to fellowship:You could join fellowship on J1 visa. Many University programs will sponsor J1 visa for their fellowship applicants. Regardless how many year you are on J1 visa, you need to complete 3 years of J1 waiver as discussed above.

So depending on your priorities and circumstances decide which visa is better for you? We hope this information will be helpful to make your decision regarding programs that sponsor H1B Vs J1 visa during residency.  

If you have any issue regarding immigration and visa, hospitals offering you residency position will refer you to their immigration lawyer. Feel free to ask for help.

Disclaimer: these are practical tips for applicants and should not be construed as legal advise.

Is this program right fit for you?

Applicants have been asking how is this program? So, what do you look into to find if this program is right fit for you?

All residency programs are certified by ACGME. So, all programs meet certain quality standard set by them. There are other factors you would like to look into to find how the programs are. Once you get interview, you should start researching on those programs and hopefully once you visit them and interview with them you have all your questions answered.

1. Community vs University program

Community programs are usually small and have limited specialty services and research activities. University program are affiliated with a university and may have multiple specialty service and more research programs. Some community hospital may be affiliated with university, but others may run independent programs without any affiliation.

You could still conduct research during your residency at community programs on quality improvement projects or retrospective chart reviews, writing case reports or case series. Ask faculty or residents during your interview regarding what different academic and research activities are residents involved and how does program facilitate them?

2. Number of residents/ Size of program/ Diversity

Certainly, your chance will be higher if program you are interviewing have many residency spots. Not necessarily, because the program will be interviewing more candidates. Also, program want to maintain diversity. Number of foreign graduates the program had in past may give you an idea regarding diversity in the program.

3. What do you want to after residency?

If you are planning to go for fellowship, look for programs whose graduates have very good fellowship placement rates. Programs also look for candidate with varied interest. Think it this way, if all residents in a program want to go for cardiology, it will not be possible for programs to support them to prepare for fellowship. So, programs from the beginning may want to take candidate who are interested in different specialty.

4. H1B vs J1 visa

With J1 visa, at the end of training you must go to underserved area for 3 years for a waiver job. IN special circumstances you could apply for hardship waiver. You will be eligible to apply for green card (GC) only after completing your waiver. So, with J1 you wait for at least 3 more years before you get your GC. However not all residency program offers H1B visa. You need to complete step 3 to be eligible for H1B. There are limited programs that support fellowship on H1B. So, if you plan to go for fellowship immediately after residency J1 as well might be good option for you.

5. Friends and family

Try to be around friends and family. You would need a lot of support. Being around them will increase your overall satisfaction and well being.

Interview Prepration

Foremost, Congratulation that you got an interview call. Interview is the time when you present your best and sell yourself. In addition to the preparation for the interview day, you need to prepare for many other things for a successful interview.

1. Communication: Be on top while communicating with programs. Respond promptly when programs reach out to you. 

- While writing an email always acknowledge and greet people personally and professionally e.g. Dear Dr. Thomas, Good morning Ms. Cook, Hello Mr. Robinson rather than just saying Hi or Good afternoon. 

- Acknowledge you have received emails from people/program. If you need time to decide about your answer, it is ok to take time, but reply to emails promptly saying that you will get back to them very soon.

- Getting an email is not enough. Answer the sender and acknowledge you received the email message. Always close the communication loop by acknowledging that you received the message.

- Write precisely what you want to tell. Do not assume people will understand your message.

- Feel free to communicate with the program if you have questions. Send them an email or message if you have new documents added or there is any change in your application. 

2. Confirm Interview dates: Once you get interview calls, reply to program with your available date promptly. Ensure you get the confirmation email. The program will send you details of the program, interview schedule, and travel.

3. Plan your travel and accommodation: You may take a train, bus or airplane to the interview. Look into options that would be convenient and affordable to you. Look for hotels, Airbnb, friends or relatives nearby who could accommodate you. Programs could recommend nearby hotels. Be prepared for winter travel; the temperature will be very cold, and snowfalls and snowstorm may cause a delay in travel.

- Use websites like Travelocity, Expedia, Google flights etc to book hotels and flight

- Use Airbnb and evolve sites to find accommodation if you want to use hotels

- Try to buy your tickets a couple of weeks in advance

- If you want to travel by bus the best options would be Peter Pan, Greyhound, Megabus etc. Look for discount offers. Sometimes Megabus offers one dollar tickets. 

4. Prepare for dinner: Some program offers an interview dinner. Try to attend them if you can. Let them know in advance if you cannot attend them. Interview dinner will be an opportunity to socialize with residents and staff. This provides an informal and relaxed setting to know more about the program and people. Research about the place you are going to, menu and type of food it offers. Avoid surprises.

5. Know people in the program: If there are people from your medical college or your friends try to reach out to them and connect with them. When you say you are from this country or place, the interviewer will ask that they have residents from that place or country and if you know them? People who are working there may be able to tell you about the program and what to expect during interviews.

6. Prepare for short talk: Greet people who come to meet you and escort you to interview rooms. Be ready for short friendly talk while you are walking to the interview room, waiting for an elevator, etc. Talking about your travel, weather, recent sports match would be a safe bet. You can ask how long is the winter there? You can share your travel experience.

7. Prepare for the interview: Be ready and thoroughly prepare for the interview. Interview questions are similar but framed differently. You must sound spontaneous and confident. Speak your heart and express yourself. Do not worry about your accent. 

8. Be ready to meet other interviewee and know them and share experience: If you have reached this stage you are damn competitive, do not worry about your score, experience, research, etc. This will be an opportunity to meet interviewee who comes from different country and background and share story and experience. 

9. Leave the interview feeling positive and energized: After every interview it is normal to feel you could have done better. Good interviewers point out your strengths and make you feel better. Take a deep breath and feel positive. Interviews are great learning experiences.

10. Remember to send thank you email: Acknowledge interviewers for their time and opportunity to interview with them. You can tell them how your interview experience was. Tell them what you liked about the program, why do you think you will be the best fit for them and how strongly you are committed to joining them.

Finally, keep fingers crossed and hope for the best.

How to succeed in clinical research and scholarly activities?

1. You certainly need to have motivation and persistence despite challenges and failures. As you start working on your first paper, you will not know how to write, you will have difficulties completing your first paper, you will have difficulty finding a mentor who can help and frequently, your paper will not be accepted by journals in the beginning. You will have to be patient and persistent. Also, you should start your research career early in your medical school e.g. when you are in your first or second year of medical school. 

2. You should improve your skills. You can use Google and Youtube videos to learn how to write a paper. There are opportunities to participate in online training or workshop. National Health Research Council provides training too. You can perhaps request your medical college or a faculty member to teach. You can learn from instructions provided in a journal on how to write various sections. Reviewing published papers can help. If you develop your skills, other people including your mentors will have interest to work with you.

 
3. Ideally, you should find a mentor who will guide you. This is difficult because mentors are busy. Working with a skillful resident in Nepal or in US may be helpful.

4. Often the first thing to work on is a case report or an abstract for a meeting. Abstract is one-page summary of a case report or a research. Before you work on a case report, carefully search the literature to determine whether the case is rare and interesting. You could also help a resident or a faculty with data collection in their project.

5. Once you have learned how to write papers, it would help you to learn how to search literature in pubmed or elsewhere, and how to use reference management software such as endnote or others. These skills will make you more efficient. 

6. You could select a target journal by looking at their impact factor and quality of published papers. For your initial papers, you should not aim high and perhaps submit to a Nepali journal or new journals. An abstract of a good case report or a research study can be submitting to a meeting including a meeting in US such as local or national American College of Physician meeting.

 
7. You should look out for opportunities to write a paper. If your medical school sends you for a field research, you may be able to publish the field work in a Nepali journal. If you know of someone working on a paper, you should approach them and offer help once you have acquired skills. 

8. Collaborating with your peers can help publish more than one paper and maintain enthusiasm despite initial failures. 


9. Once you are skillful, you may be able to obtain grants from different organizations. 

Physicians who want to have successful career in US should really learn skills to write papers and conduct research. These skills improve with time and practice but self-motivation and persistence are key.

Shake hands like Barrack: Busting common myths about residency application

By Iva Neupane

1. AMG do not have good score.

Wrong: they have excellent score plus – they manage to do more during their undergrad and med school e.g. actually volunteer in remote countries, publish papers, are into sports and also manage to play piano…(hope you got the picture). Luckily, these applicants are very ambitious, thus would prefer to go to top tier programs-that means more spots for IMG in community hospitals. Since most of the program now have to go for match, good chances for IMG to match in university program: so, spend your money carefully.

2. I never did much for my cv, its already too late.

Nope: start today- look for ways that can add more to your CV. Volunteer at local hospital (Nepal or US), health camps, teaching -schools/community( teach English at local govt school…just do something for others). Look for opportunity to do observership even if you don’t get LOR on time. Keep looking and keep doing whatever is feasible at that time.

3. It’s very hard “this year”.

Trust me I hear this every year!!!  This is your journey and its known to be hard one. Stop whining about it already!!!

4. You can only do medicine, pediatrics or psych.

Wrong. USA still needs a lot of primary-level provider (PCP, hospitalist, general pediatrician and psychiatrist) – demand is higher for these specialties. But if you want to be a surgeon, you can- you just have to try harder-better score, better CV and also be ready for the vigorous training.

5. I don’t have US LOR- so my chances are slim: not entirely true.

If you can, try to get a US LOR. If it’s not possible/time crunch-don’t cry about it.  LOR written by prominent figure or someone who is familiar to the program definitely weighs more. However, I don’t think LOR from a Dr Smith or Dr Sharma don’t outweigh each other.

6. People who already have done residency in home country have better chance.

Not really. Residency in USA is supposed to be for those who just got out of med school. There are specific requirement and the training is supposed to be done in a specific manner: expectations are clear.  A residency in your home country can makes you more mature and knowledgeable but that does not add much weigh to what kind of trainee you become during your residency here in US.

7. I can say whatever abut Nepal during interview, what would they know?

You could not be more incorrect.  My Program Director knew how we IMG studied: she knew we take some time off after med school, are super score oriented. Also, lots of colleagues I know have been to Nepal: so please do not tell them anything crazy. I once interviewed somebody who wrote in her CV that she could speak Nepali because she did her med school in Assam. At the end of interview, I asked her to say something in Nepali. She said something that did not made sense. I did not tell her that I’m Nepali as I did not want to embarrass her.

8. My English is not good: my chances are slim.

Give and take -most of the program understand that English might not be your mother tongue and you would have an accent.

My division secretary still corrects my pronunciation. The only way to improve is listen and practice (talk to yourself in the mirror).

9. I don’t speak Spanish/ French or whatever language to match in that region. There is a thing in every hospital in the USA called “interpreter service”. As long as you speak English and you are good on your CV, you are all set.

10. I don’t care about fashion; I am a doctor.

Well, you don’t have to wear the fashion ramp but make sure you and your luggage do not smell. Clean hair and nail please. I am writing this because I have had experience with these.

Smile is the best accessory!! Guys do good with suits. Girls, its ok to wear skirt (My PD always wore skirt, she was in her 60s) and please tuck your shirts. No loud make up but a gentle touch it good.

Moral of the story is: you need to look as if you care about this interview and you made an effort to look your best.

11. It’s too early to write personal statement.

This takes time. Unlike the other steps in the application, this one is very subjective and requires a lot of effort to make it stand out. Start writing a draft as soon as possible, you might have to re-write it many many times, have everyone read it and edit it. This might take months. A good personal statement would not get you a residency but a bad one definitely makes a bad impact. You do not want to be remembered as “the one with bad personal statement”.

12. To get into residency is very hard.

Well, this is what it’s supposed to be. Hundreds and thousands of people go through the same. If you were able to get through MBBS, you can absolutely get through this. Perseverance is the key word here. STAY POSITIVE AND FOCUSED AND YOU WILL GET IT!!!

13. Common etiquette: 
Practice firm handshake. Start practicing on your parents, siblings, everyone you meet in the street. Stand straight when you shake hand (watch Obama videos), do not bend as if you are going to touch their legs for blessings.

Don’t get too close to anyone, “personal space “is real thing here in US.

Make sure you Open the door/hold the door for any female and older adult. Start practicing this on your mother, wife, sister and friends already!!

Birthdays are special here. Even older people celebrate their birthdays. Please be mindful.

Iva Neupane is an attending Physician and Faculty at The Geriatrics Department, Rhode Island Hospital. She did her Residency in Internal Medicine at Saint Vincent Hospital and also worked as a Chief Resident. She completed her Geriatric Fellowship at The Brown University in Providence. She speaks from her experience as a chief resident and a faculty interviewing and selecting residents and fellows.