Obtaining a J1 waiver and transitioning to an H1b Visa
Congratulations!!! You have made it to residency on a J1 visa and you will either go on to a fellowship program on a J1 visa or find an attending job in which case you will have to transition to a working visa (H1B or O1 visa). Since I am on an H1b visa, the following discussion is mainly regarding my personal pathway.
If you are on a J1 visa, you can take one of two pathways (if your country is subject to the home residency requirement):
1) Fulfill the home residency requirement:
Physically reside in your home country for two years. You can, but do not have to work as a physician or even work at all. If you are a Canadian, you could work for two years in the United States close to the border (e.g., Michigan or New York State) while commuting from Canada and still fulfill the home residency requirement. Paraphrased from my immigration attorney, the United States counts fulfilling your home residency requirement by “where you rest your head at night”. If you are living in Canada, employment across the border is still possible.
2) Obtain J1 waiver then H1b visa:
You have to work three years in a geographically underserved area or at a facility, which provides for an underserved population. The Conrad 30 program through the state where you plan to work governs the J1 waiver process, which culminates in an H1B visa. See this article for further details.
Does the geography of your job (defined by zip code) qualify as “Medically Underserved”? Find out here.
There are 5 ways to qualify for a J1 waiver:
No objection statement: United States law does not permit foreign medical graduates who acquired exchange visitor (J1 visa) status on or after January 10, 1977 to receive graduate medical education or training to use this option
Fear of persecution
Exceptional hardship to a U. S. citizen or lawful permanent resident
Request by a State Health Department (Conrad 30 program)
Interested United States Federal Government agency:
Appalachian Regional Commission
Delta Regional Authority
Department of Veterans Affairs
Department of Health and Human Services
Looking for a job after your residency or fellowship training needs to start as early as possible to begin building a network of potential employers and resources. I began looking at options for employment and learning about the visa process in my 4th year of residency and once I realized this was something beyond my capabilities and this process required professional services (I was in the beginning of my fellowship year when this dawned on me), I found a physician immigration firm and asked for help.
Let us discuss the options available post J1 visa:
The H1b visa lottery system has been in flux the last several years so I will not comment further on the process; however, I did apply for this process while I was in my fellowship year and was not successful via this route. The system has proposals to be revamped according to an article by Forbes.
At the end of my fellowship, I was unable to find a desirable position in my home country and decided to pursue a J1 waiver through the Conrad 30 program. This was a personal decision. If you are financially independent (Financially Independent Retire Early), you could take a two-year hiatus from medicine. That was not an option for me and my feeling of being out of practice for two years could negatively impact my ability to be hired. I could have worked locum tenens in Canada, but the options were limited, and the financial risk vs benefits did not equate. After medical school, residency, and fellowship in multiple cities and countries and on multiple visas, I wanted to start my career in earnest.
During residency and fellowship meetings (College of American Pathologists and National Association of Medical Examiners), I explained my immigration situation and difficulties obtaining a job post fellowship to as many colleagues as possible to get the word out and create a network. I succeeded in finding an institution to sponsor me for the J1 waiver. The particular state at the time did not recognize my specialty (Forensic Pathology) as eligible for a waived specialty. Different states have different specialties listed for waiver positions (Click here to link to the state of interest). However, the director of operations, the J1 visa waiver contact of that state and my personal immigration lawyer successfully petitioned the state to recognize my specialty as “direct patient care”. I became the first Forensic Pathologist with a J1 waiver in that state!!!
A particularly important nuance to this process is that the person who is preparing your paperwork from the employer side does not necessarily have to be a lawyer. A very diligent administrator (in my case a former police officer who became the director of operations of the Medical Examiner’s Office) handled the paperwork with a lot of guidance and meetings with my personal immigration attorney and the J1 waiver contact of the State. Do not be deterred if the office or your potential employer does not have a lawyer on retention or an in-house counsel. Your immigration attorney is what you truly need to get things done.
The extra work of petitioning to have my specialty added to the list of eligible waiver positions (getting the state to recognize that Forensic Pathology is direct patient care), created a time delay. As a resident physician on a J1 visa, you can apply for an extension to stay in the United States to take your boards in the Fall. I obtained an extension and moved in with my best friend while in Southern California and then moved in with my then boyfriend & soon to be husband in New Jersey to save on extra costs of living while unemployed. There are considerable costs, which may be incurred during the J1 waiver to H1b visa process. Make sure you have sufficient funds in reserve. After writing your boards, you have a 30-day grace period to remain in the United States and after those 30 days, you must leave the United States. I returned to Canada and waited for the J1 waiver to be issued after it was submitted for approval in October of 2017, which was followed by the H1b visa issued in February of 2018. The total time in the USA post fellowship was 4 months and in Canada was another 4 months.
The entire process of getting a waiver established for forensic pathology is summarized below which is also published on the National Association of Medical Examiner’s website Microsoft PowerPoint - NAME presentation 2018 updated (memberclicks.net).
Consultation of a physician immigration attorney (1-2 months)
Interview for job (1-2 months)
Recognizing Forensic pathology as direct patient care (~10-12 months depending on the budgeting year of that state)
Obtaining J1 waiver (2-3 months depending on government shutdowns)
Obtaining an H1b visa and beginning work (2-3 months depending on government shutdowns)
TOTAL TIME: 18-22 months
Some specialties and most primary care physicians are already accepted as direct patient care depending on the state of practice and this timetable is not applicable. If your specialty is already established on the list of waived specialties, a J1 waiver and H1b visa sponsorship can be completed within 8 months of your fellowship year or final year as a resident.
Financial Costs to consider if you find yourself in immigration limbo:
1. COBRA coverage. Note, COBRA coverage will cost more if you move to a state other than where you were receiving healthcare. I used COBRA coverage while I was staying in the United States after fellowship.
2. Possible storage of personal belongings
3. J1 waiver fee (~$9000) *
4. Expedited fee (~$1250) *
5. Food and lodging
6. Miscellaneous recurring fees (e.g. car and disability insurances)
*Fees increase each year, check with USCIS and your immigration attorney for the most up-to-date information when planning your budget. Expedited fees apply to your application. If you pay this fee, you will get a response from USCIS if your application was accepted or rejected within 15 business days. They are especially useful if you find yourself in a situation of unemployment. The government vacillates between suspending and accepting these fees.
Who pays for the J1 waiver and H1b Visa (applicant or sponsor or both)?
In the best of all possible worlds, you are fortunate and find an employer who will pay your J1 waiver fee, expedited fee and H1b visa. A more likely scenario is you will pay a portion of the bill. By law, the sponsor must pay the H1b visa fee, ~$7000-10,000. It is illegal for the sponsor to ask for this money or garnish your wages as repayment. The J1 waiver and expedited fee can be paid by the sponsor or by the applicant. I ended up paying for the J1 waiver and expedited government fee.
My experience crossing the United States-Canadian border:
If you find yourself in a situation similar to mine where you have to leave the country due to your visa expiring and you have 7 years’ worth of “stuff” in storage that you do not want crossing into Canada with you because you have applied for a J1 waiver, be sure to have a list of all of your belongings (in as much detail as possible) as you will have to provide this to the Canadian border services. If you do not get a H1b visa and have to return to your home country permanently, listing your belongings on the form will allow for duty free importation of your personal property. If you do not write everything down, an import fee will be assessed.
This advice is exclusively for Canadians: I purchased my car in the United States (and ironically it was manufactured in Canada and imported to the USA….it was kismet!). Be sure to have the title or lease documentation with you. Your car must be inspected by the Registrar of Imported Vehicles (RIV) in Canada. I was taxed on the air conditioner and paid $300 import tax as they looked up the value of my car in the Kelly Blue Book. I had to then take my car to a certified garage (Canadian Tire) for an inspection to ensure that my car was up to the Canadian environmental standards. Thankfully, my car had daytime running lights already built in and the ability to display my speedometer in both Kilometers and miles. I did not have to modify my car in any way and my car door now sports an extra sticker that it has been Canadian certified and passed inspection. My next step was to register my car with the Ministry of Transportation and get an Ontario license plate. I chose to stop this process after getting my inspection and parked my car at my parent’s residence and used their car if I had the need to commute. Had I not obtained my J1 waiver and H1b visa, I would have completed the entire process of importing my car.
The whole process at the border with my car and documenting my belongings took approximately 2 hours. My advice is to be honest and courteous with border patrol. They assume you have been told all of this information prior to leaving the US so patience is key.
I missed the budgeting year for my State to apply for the J1 waiver, what can I do?
This is unfortunately a common scenario in the field of forensics where an H1b visa cannot be obtained in time for a fellow to begin their attending job right after fellowship training. An option, which I have no personal experience in but have heard of and conceptually understand is obtaining an O1 visa. This visa acts as a bridge to keep you legally present in the United States AND employed. This visa DOES NOT absolve you of your J1 visa commitment of a home residency requirement; however, it does buy time to apply for the next cycle of the J1 visa waiver and obtain an H1b visa. You can also work more directly with your employer to help “convert” that state into a J1 waiver state for your specialty and become a Trailblazer!
See “Guest Posts” for a story of a Dermatologist from Canada on an O1 visa.
