Table of Contents
Credits
Host: Sara Dong
Guest(s): Ana Del Valle, Cristina Tomatis, Diego Cruz, Radhika Sheth, Shweta Anjan, Zheyi Teoh, Cesar Berto
Edited and produced by Sara Dong with support from the Infectious Diseases Society of America (IDSA)
Our Guests
Ana Del Valle, MD
Ana Del Valle is originally from Monterrey, Mexico where she completed medical school before moving to the U.S. for pediatric residency and pediatric infectious disease fellowship. She is now an Assistant Professor of Pediatric Infectious Diseases at Arkansas Children’s Hospital, where she is completing her J-1 visa waiver.
Cristina Tomatis, MD
Cristina Tomatis was born and raised in Lima, Peru, where she completed medical school. She completed residency in Madrid, Spain and then went to Columbus, Ohio for fellowship where she has since stayed. She had to repeat residency prior to becoming an Assistant Professor at Nationwide Children’s Hospital. At Nationwide, she does general ID (with some transplant) as well as translational research about immune response to vaccines.
Diego Cruz, MD
Diego Cruz is a current Pediatric Resident at Nationwide Children’s Hospital after completing Pediatric Infectious Disease fellowship in the same institution. He is originally from Cali, Colombia where he completed Medical School and Pediatric Residency at Universidad del Valle.
Radhika Sheth, MBBS
Radhika Sheth is an adult infectious disease physician with Henry Ford Health System in Michigan. She also works closely with the internal medicine residency program and is involved in medical education. She is originally from India, where she completed medical school.
Shweta Anjan, MD
Shweta Anjan is an adult transplant infectious diseases physician and TID fellowship director at University of Miami and Jackson Memorial Hospital, Miami Florida. She is originally from India, and completed medical school from Kasturba Medical College, Manipal before moving to the US in 2012.
Teoh Zheyi, MBBS, MPH
Teoh Zheyi is a pediatric infectious diseases faculty at Seattle Children’s Hospital and is a transplant infectious diseases doctor. He is originally from Malaysia, completed his fellowship training at Cincinnati Children’s, and obtained a J-1 persecution waiver before joining faculty.
Cesar Berto, MD
Cesar Berto is a transplant infectious diseases faculty member at the University of Alabama at Birmingham (UAB). Originally from Lima, Peru, he is currently completing his waiver.
Culture
Ana Del Valle: the podcast Normal Gossip
Cristina Tomatis: seeing the Dog Man musical at the Southern Theater in Ohio
Diego Cruz: Wheel of Time book series
Radhika Sheth: Children of Time by Adrian Tchaikovsky
Shweta Anjan: trip to Istanbul and Turkish coffee
Teoh Zheyi: backcountry skiing
Cesar Berto: The Notebook musical
Consult Notes
Updates on US ID Fellowship Match
- Congratulations and welcome to all of the new incoming ID fellows! We have over 310 new adult ID physicians and over 40 incoming pediatric ID docs! There was a slight increase in the number of matched individuals with a largely stable percentage of programs filled.
- NRMP Match Results Statistics, Medicine and Pediatric Specialties – 2024, Overall Statistics
- NRMP Results and Data Specialties Matching Service, 2024 Appointment Year
- Official IDSA/PIDS statement on 2024 fellowship match: https://www.idsociety.org/news–publications-new/articles/2024/idsa-and-pids-statement-on-2024-id-fellowship-match/
| Adult 2025 Appointment | Adult ID 2024 Appointment | Adult ID 2023 Appointment | Pediatric ID 2025 appointment | Pediatric ID 2024 Appointment | Pediatric ID 2023 Appointment | |
| Certified programs | 179 | 189 | 175 | 59 | 53 | 56 |
| Programs filled | 91 (50.8%) | 96 (50.8%) | 98 (56%) | 25 (42.2%) | 20 (37.7%) | 24 (43%) |
| Programs unfilled | 88 (49.2%) | 93 (49.2%) | 77 (44%) | 34 (57.6%) | 33 (62.3%) | 32 (57%) |
| Certified positions | 450 | 450 | 441 | 89 | 77 | 81 |
| Positions filled | 316 (70.2%) | 303 (67.3%) | 328 (74%) | 43 (48.3%) | 37 (48.1%) | 40 (49%) |
| Positions unfilled | 134 (29.8%) | 147 (32.7%) | 113 (26%) | 46 (51.7%) | 40 (51.9%) | 41 (51%) |
What is an IMG?
- International Medical Graduate (IMG) in the US is a physician who has graduated medical school from outside of the US or Canada
- IMG may be a US citizen or permanent resident (“Green card” holder), or a citizen of another country
- An IMG applying to subspecialty fellowships may have completed an ACGME accredited residency, or may have completed residency-equivalent training abroad
- IMGs comprise about 25% of the US physician workforce
- Duvivier RJ, Gusic ME, Boulet JR. International Medical Graduates in the Pediatric Workforce in the United States. Pediatrics. 2020;146(6):e2020003301. doi:10.1542/peds.2020-003301
- Norcini JJ, van Zanten M, Boulet JR. The contribution of international medical graduates to diversity in the U.S. physician workforce: graduate medical education. J Health Care Poor Underserved. 2008;19(2):493-499. doi:10.1353/hpu.0.0015
- The proportion of US-IMGs matched into ID was increased this year
Our guests spoke about the landscape of training on a visa
- In the episode, you heard a description of waiver positions along with drawback and limitations. Here are a few resources mentioned on the show.
- For someone that requires a visa to train in the US, they are usually on two types of visa: J-1 or H-1
- J-1 is exclusively a training visa, whereas the H-1 is a temporary work visa. You can see a compare/contrast chart below
- Al Ashry HS, Kaul V, Richards JB. The Implications of the Current Visa System for Foreign Medical Graduates During and After Graduate Medical Education Training. J Gen Intern Med. 2019 Jul;34(7):1337-1341.
- The most common J-1 waiver is the Health and Human Services Exchange Visitor Program (aka Conrad 30), in which each state has a limit of 30 waiver positions. There are other waiver positions though, some examples are summarized below:
Table: Overview of the various mechanisms, and their limitations, used by international medical graduates to obtain J-1 waivers
| Waiver type | Requirements | Limitations for PID physicians |
| Conrad-30 | Work in a federally designated health professional shortage area (HPSA) or medically underserved area (MUA) for at least 3 years | • Reliant on employers to file application • Meeting fall deadline requires an expediated timeline for job interviews and acceptance (often between second and third year of PID fellowship)36 • Waiver positions can be competitive, and in certain states, positions can fill within hours after applications are accepted36,37 • Not all hospitals or PID positions are federally designated as HPSAs or MUAs • Preference for waiver positions given to primary care physicians, with some states placing restrictions on the number of subspecialties positions sponsored • Accepted position’s full-time equivalent must contain at least 80% of direct patient care |
| Interested U.S. government agency | Sponsorship by an interested government agencies, most relevant to PID are: Appalachian Regional Commission (ARC), Delta Regional Authority (DRA), Southeast Crescent Regional Commission (SCRC), and Northern Border Regional Commission (NBRC) | • Reliant on governmental agency to file application • ARC, DRA, SCRC, and NBRC only apply to a limited geographical setting, primarily in the South, Southeastern, and Eastern states. • Additional paperwork and documentation needed to demonstrate need for and lack of subspecialists in the region • Waiver positions’ full-time equivalent must meet minimum percentage of direct patient care (up to 100% for certain agencies and/or regions) |
| Persecution or Hardship | Establish “well-founded fear of persecution” in home country or “exceptional hardship” to U.S. citizen or permanent resident spouse or child | • Uncommon mechanism to obtain J-1 waiver with many IMGs not meeting eligibility • Complex mechanism, requiring high burden of documentary proof (e.g. multiple affidavits of support, media reports, and grey literature to document persecution or hardship) • Challenging and expensive to find lawyer with sufficient experience for this specific waiver • Lengthy process, taking as long as 14.5 months to complete processing11,33 • Should only be filed prior to last year of fellowship, leading to potential delays between graduating and starting new position |
Here is another example table:
Several of the guests authored this helpful overview in JPIDS
Teoh Z, Erdem G, Tomatis-Souverbielle C, et al. Overcoming Challenges for Non-US International Medical Graduates in Pediatric Infectious Diseases. J Pediatric Infect Dis Soc. 2024;13(7):374-378. doi:10.1093/jpids/piae050
- This paper shaped most of the latter part of the discussion. Check out how they outlined some of the challenges and possible solutions by different stakeholders:
- the Non-US IMG themselves
- Fellowship program leadership and other mentors/colleagues
- Division and institutional leaders
- And lastly national societies
- Please check out the audio to hear from our amazing panel. Some take-homes from our guests and mentioned links:
- Programs who recruit IMG fellows and the trainees themselves should be aware that the process of finding a job is a time sensitive one, especially if you are on a J1 visa. Start your search early and ideally have a few job interviews lined close to the end of your first year. If applying through the CONRAD program, check your state rules about deadlines for contract and paperwork submission.
- It is not only the ID program – but the Department Chair and administration in the hospitals that may be a barrier as well — if recruitment cannot accommodate or adapt to these applicants, they have even less options no matter how knowledgeable the ID program is
- Our guests highlighted the challenges for IMGs who may be interested in research. Many adult ID IMG fellows will not be eligible to do a third year since they cannot apply for NIH grant funding (eg. K/T32) as non-US citizens. This severely limits research experience as trainees. It also continues to affect faculty who might want to do research and can impact promotions and academic progress. Aldo Barajas-Ochoa, Comment on: A Call to Action: Urgently Strengthening the Future Physician-Scientist Workforce in Infectious Diseases, The Journal of Infectious Diseases, Volume 230, Issue 3, 15 September 2024, Pages 778–780, https://doi.org/10.1093/infdis/jiae271
- Check out the PIDS IMG initiatives such as IMG-specific IDA&E grand rounds. Here are some links:
- Also look at the PIDS IMG Early Career Development Award: https://pidsfoundation.org/international-medical-graduate-early-career-development-award
- Support legislative advocacy efforts that may be more impactful from large societies as well as advocacy efforts within our professional board organizations (ABIM and ABIP) around international medical training and sitting of subspecialty boards
- IDSA career roadmap to ID
Infographics
Goal
Listeners will be able to identify challenges of international medical graduates seeking waivers to work in the US
Learning Objectives
After listening to this episode, listeners will be able to:
- Define “international medical graduates”
- Compare and contrast the most common mechanisms and limitations of J-1 waivers used by IMGs
- Discuss strategies to support IMGs who choose to train in infectious diseases
Disclosures
Our guests as well as Febrile podcast and hosts report no relevant financial disclosures
Citation
Del Valle, A., Tomatis, C., Cruz, D., Sheth, R., Anjan, S., Teoh, Z., Berto, C., Dong, S. “#113: Season 4 Finale: Match Update & Supporting IMGs in ID”. Febrile: A Cultured Podcast. https://player.captivate.fm/episode/b5811a3e-e227-4194-9da3-7d60d8aad9f4/