Proper medical licensing and visa documentation is required for all housestaff in McGaw programs. Following are details related to licensing and visas – including applicant requirements reprinted with permission from www.acgme.org.
GME is the principal liaison with the State of Illinois Department of Financial and Professional Regulation (IDFPR) for medical licensing. Please note that licensing is extremely important as housestaff cannot perform clinical activities or be paid without a valid medical license. The initial licensing process can be lengthy—a doctor needs to allow 60 days for processing of initial application. GME deals mainly with three kinds of licenses: temporary, permanent, and limited licensed temporary.
Temporary licenses are issued for a period of up to three years and can be extended for the length of the program. All newly appointed housestaff can download an application from the IDFPR website. Complete the application and send to the GME office for review.
Housestaff are eligible to obtain a permanent license after successful completion of 24 months of training. We recommend that all fellows obtain a permanent license.
Limited Temporary Licenses
These licenses are needed for out-of-state visiting trainees who are completing a rotation at McGaw. If the GME office is informed of the trainee’s rotations, we will assist the doctor in obtaining this license. Licenses are good for a maximum of six months.
Problems that Delay Licenses: Visas for International Medical Graduates
Entry of Foreign-born Medical Graduates to the United States
The entry of foreign-born graduates of non-US medical schools to the United States is governed by the US Immigration and Nationality Act (INA), as amended, which is administered by the US Immigration and Naturalization Service (INS). It is a violation of federal law to provide employment to a non-US citizen who does not hold a visa permitting employment or other appropriate work authorization documents from the INS. Thus, residency program directors considering foreign-born international medical graduates (IMGs) should appoint only those who hold an exchange visitor (J-1), temporary worker (H-1B) or immigrant visa, or an INS-issued or -approved work permit. These foreign-born IMGs should also hold the Standard Certificate of the Educational Commission for Foreign Medical Graduates (ECFMG).
Certification by the Educational Commission for Foreign Medical Graduates
The ECFMG, through a program of certification, assesses the readiness of IMGs to enter US residency or fellowship programs that are accredited by the Accreditation Council for Graduate Medical Education (ACGME). The ECFMG and its sponsoring organizations define an IMG as a physician whose basic medical degree or qualification was conferred by a medical school located outside the United States, Canada, and Puerto Rico. The medical school must be listed at the time of graduation in the World Directory of Medical Schools, published by the World Health Organization. US citizens who have completed their medical education in schools outside the United States, Canada, and Puerto Rico are considered IMGs, while foreign nationals who have graduated from medical schools in the United States, Canada, and Puerto Rico are not.
ECFMG certification provides assurance to ACGME-accredited residency program directors and to the people of the United States that IMGs have met minimum standards of eligibility required to enter such programs. ECFMG certification is also a prerequisite required by most states for licensure to practice medicine in the United States and is one of the eligibility requirements to take Step 3 of the United States Medical Licensing Examination (USMLE).
To meet the medical education credential requirement for ECFMG certification, applicants must have completed all the educational requirements to practice medicine in the country in which they received their medical education. A national of the country concerned must have an unrestricted license or certificate of registration to practice medicine in that country.
All medical credentials received by the ECFMG are sent by the ECFMG to the foreign medical schools for verification by the appropriate officials. ECFMG medical education credential requirements are not fulfilled until such verifications are received by the ECFMG.
To meet the examination requirements for the ECFMG certification, an applicant must:
- Pass the medical science examination (Step 1 and Step 2 of the USMLE are currently administered for this purpose). Although the 1-day ECFMG medicine examination, the 2-day Visa Qualifying Examination, the Part I and Part II examinations of the National Board Of Medical Examiners (NBME), and Day 1 and Day 2 of the Foreign Medical Graduate Examination in the Medical Sciences are no longer administered, a passing performance on any of those medical science examinations is accepted for ECFMG certification. Also, applicants are permitted to combine the basic medical science test of one of these examinations with the clinical science test of one of the other examinations.
- Additionally, the 3-day Federation Licensing Examination (FLEX) is accepted for ECFMG certification if taken prior to June 1985 and a score of 75 or higher on each of the 3 days of a single administration has been obtained.
- While foreign national physicians may meet the medical science examination requirement for ECFMG certification based on the former 1-day ECFMG examination, last administered in February 1984, or FLEX taken prior to June 1985, these examinations have not been recognized by the US Secretary of Health and Human Services as meeting the medical science examination requirement to obtain a visa to enter the United States. See below.
- Pass the ECFMG English test. The only alternative English test the ECFMG will accept is a Friday or Saturday (formerly special or international) administration of TOEFL (Test of English as a Foreign Language), provided that applicants have previously taken an ECFMG English test. Passing performance on the English test is valid for 2 years.
A Standard ECFMG Certificate is issued to applicants who meet the medical science and English language requirements, fulfill the medical education credential requirement, and clear their financial account with the ECFMG.
The Standard ECFMG Certificate is considered valid for entry into an ACGME-accredited graduate medical education program so long as passing performance on the English test has not expired. If the holder of the certificate has entered such a program in the United States prior to the English test expiration date, the certificate is no longer subject to expiration. In order for an applicant to obtain permanent revalidation for the certificate, the ECFMG must receive documentation from an official of the program confirming the applicant's entry into the program. On receipt of such official documentation, the ECFMG will provide a revalidation sticker to the holder of the certificate. Standard ECFMG Certificates may also be revalidated for a period of 2 years by passing a subsequent ECFMG English test or TOEFL.
For further information on ECFMG examinations and certification, contact
3624 Market Street
Philadelphia, PA 19104-2685
Legal fees for H-1B visas
The US Citizenship and Immigration Service (USCIS) regulates and monitors H-1B visas. Effective January 1, 2010, if you accept an international graduate into your program who will be obtaining an H-1B visa, your department/division is responsible for all legal fees incurred. USCIS does not permit the trainee to pay these fees. Fees can vary from $2,000 to $5,500. All checks must be issued in the name of our McGaw immigration attorney, John Colbert, and forwarded to the GME office to ensure the timely processing of the documents.
Note that this does not apply to international graduates on a J-1 training visa.
Exchange Visitor J-1
Foreign national physicians use the exchange visitor J-1 nonimmigrant visa class most often for graduate medical education and training. The Exchange Visitor Program is regulated by the United States Information Agency (USIA), which designates various organizations and educational institutions as Exchange Visitor Program sponsors. Each designation is designed for a specific purpose appropriate to that sponsor. The USIA has designated the ECFMG as the only organization authorized to sponsor foreign national physicians to engage in graduate medical education or training. Such education or training is defined in the US Code of Federal Regulations as participation in a program in which the foreign national physician will receive graduate medical education or training, which generally consists of a residency or fellowship program involving the provision of health care services to patients. This program may consist of a medical specialty, a directly related medical subspecialty, or both.
To be eligible for ECFMG exchange visitor sponsorship for graduate medical education, the foreign national physician must pass either the National Board of Medical Examiners (NBME) former Part 1 and Part 2 examinations, or an examination determined to be equivalent to the NBME by the Secretary of the US Department of Health and Human Services. The following examinations have been determined to be equivalent to the NBME Part 1 and Part 2 examinations for this purpose:
- Day 1 and Day 2 of the former Visa Qualifying Examination;
- Day 1 and Day 2 of the former Foreign Medical Graduate Examination in the Medical Sciences; and
- Step 1 and Step 2 of the United States Medical Licensing Examination.
In addition, the foreign national physician must:
- Hold a valid Standard ECFMG Certificate;
- Have a contract with an ACGME-accredited program that is affiliated with a US medical school; and
- Provide a written statement from the Ministry of Health in the country of most recent legal permanent residence that attests to the need for physicians trained in the exchange visitor's specialty and that verifies that the exchange visitor has filed written assurance that he/she will return to the country upon completion of training.
The duration of participation for exchange visitors in graduate medical education is the time required to meet the educational requirements for certification by an American specialty board that has been recognized by the American Board of Medical Specialties. Duration of participation is further limited to a maximum of seven years.
Exchange visitor physicians who enter the United States for the purpose of graduate medical education are automatically subject to the 2-year home physical presence requirement of the Immigration and Nationality Act as amended. This means that prior to applying for H (temporary worker), L (intracompany transferee), permanent resident, or immigrant status, the exchange visitor must reside and be physically present in the country of most recent legal permanent residence for an aggregate of at least two years.
Foreign nationals who are graduates of Liaison Committee on Medical Education (LCME)-accredited US and Canadian medical schools and who wish to enter the United States for the purpose of graduate medical education are also eligible for ECFMG sponsorship. They are not required to hold a Standard ECFMG Certificate. However, they must meet the other requirements for exchange visitor sponsorship and are held to the two-year home country physical presence requirement.
An uncommon, but possible case, occurs when an exchange visitor is a medical trainee in J-1 student status at a US college or university. Such trainees who graduate from US LCME-accredited medical schools are eligible for up to 36 months of postdoctoral academic training in the field of study. Graduates of US medical schools may, therefore, use academic training authorization to undertake a residency that can be completed within the three-year time limitation. This work must be authorized by the school from which the student graduated. The J-1 "responsible officer" at the US medical school can usually provide information necessary to make employment eligibility determinations for these graduates.
Foreign national physicians who wish to enter the United States for advanced training may do so in programs involving observation, consultation, teaching, or research with or without patient contact incidental to one or more of these activities. The ECFMG is authorized to sponsor foreign national physicians for this purpose. The USIA may also authorize universities and other health science institutions to sponsor foreign national physicians for this purpose.
However, J-1 (exchange visitor) status physicians who enter the United States in the J-1 visa categories of student, research scholar, or professor may not, as a matter of course, change their J-1 visa category to alien physician to allow them to engage in graduate medical education or training sponsored by the ECFMG. Said physicians must (through the ECFMG) present a request for visa category change to USIA for review and decision. The request must demonstrate unusual and extenuating circumstances. Exchange visitors in programs involving observation, consultation, teaching, or research may remain in the United States for a maximum of three years with a possible six-month extension under specific circumstances.
Temporary Worker H-1B
The H-1B visa is for temporary workers in specialty occupations who hold professional level (bachelor's degree minimum) appropriate to the employment in which they will be engaged. Between 1976 and 1991, graduates of foreign medical schools were not permitted to use the H-1B for residencies, except in the cases where individuals were of national or international renown. The Immigration Act of 1990, and subsequent technical amendments, made the H-1B available to graduates of foreign medical schools who have passed FLEX or the equivalent, have passed an English language exam, and hold a license appropriate to the activity. The Secretary of the Department of Health and Human Services has determined that the USMLE Steps 1, 2, and 3 or the former NBME Parts 1, 2, and 3 special certifying examination sequence are equivalent to FLEX for this purpose. The level of licensure required is determined by the state and by the activity. For example, in many states a limited or training license is sufficient for a residency and would be acceptable for the H-1B.
Due to the FLEX or equivalent examination requirement and the requirement in most states that physicians complete a certain amount of US training prior to admission to the third or final portion of the licensure exam, it is likely that only a small number of physicians will qualify for and use the H-1B visa for residencies. Because the purpose of the J-1 (exchange visitor) visa is to provide foreign nationals with opportunities to participate in educational and cultural programs in the United States, many individuals and organizations agree that the J-1 visa is the appropriate visa for the purpose of graduate medical education.
H-1B employment authorization is employer-specific, so that the training program must file an H-1B petition on behalf of the international medical graduate. An H-1B visa obtained for a particular program may be used only for that program and is not transferable to another institution or program. The total amount of continuous time permitted in H-1B classification is 6 years; no extensions are permitted. An absence from the United States of one year or more restarts the six-year period.
There are some exceptions and special circumstances. Graduates of LCME-accredited US medical schools are exempt from the FLEX and English language examination requirements. Graduates of LCME-accredited Canadian medical schools are exempt from the English language exam, but not the FLEX exam. Interestingly, full licensure in Canada based on Canadian examinations, which may be reciprocal for full licensure in a US state, is not equivalent to FLEX for H-1B purposes. The FLEX, or its equivalent, is still required even if these physicians hold full licensure in the state in which training will occur.
F-1 Student Postcompletion Practical Training
Trainees in F-1 status may be authorized for up to 12 months of practical training after completion of studies, provided the practical training program can be completed in 12 months. IMGs who receive US medical degrees while in F-1 status may apply to INS for practical training work authorization. If employment authorization is granted, the individual may use that authorization for residency training for a period of 12 months. The F-1 "designated school official" at the US medical school can usually provide information necessary to make employment eligibility determinations for these graduates. Note that graduation from a US PhD program does not permit practical training in graduate medical education, since the PhD prepares one for research, but not for clinical practice. Employment Authorization From the US Immigration and Naturalization Service (INS) is empowered to grant employment authorization to certain non-immigrants or intending immigrants. Such authorization is usually temporary and may have conditions.
A common employment authorization in academic institutions is that given to the J-2 spouse or child of a J-1 exchange visitor. J-2 dependents may apply to INS for work authorization provided it is not to support the principal J-1. When granted, it permits any employment for which the individual is qualified, including residency training. Residency program directors are cautioned that this employment authorization is absolutely dependent upon the J-1 exchange visitor maintaining status. If the J-1 leaves the United States, or fails to maintain status, the J-2 work authorization ends, even though he/she may hold a J-2 employment authorization document that appears to be valid.
Other classifications or circumstances under which the INS may grant work authorization include, but are not limited to, G-4 dependent of a foreign government employee in the United States, temporary protected status, voluntary departure, refugee, asylee, or certain lawful permanent resident applicants. These must be evaluated case by case.
Lawful Permanent Resident (Immigrant) Status
Persons who hold lawful permanent resident or "green card" status are permitted to remain in the United States permanently and to accept any employment for which they qualify. For appointment to a residency program, IMGs must meet the requirements described in the Essentials of Accredited Residencies in Graduate Medical Education (see Section II).
Foreign-born international medical graduates may immigrate to the United States based on relationship to a US citizen, becoming a lawful permanent resident, or through employment and skills. In general, the rules for immigration are the same for international medical graduates as for any other immigrant, but special rules apply to physicians who immigrate based on their intention and ability to practice the profession of medicine, including practice at the residency level. Employment-based immigration based on a job offer for the practice of medicine requires that the physician pass the NBME Parts 1 and 2 examinations, or the equivalent as determined by the Secretary of the US Department of Health and Human Services. These are the same examinations needed for ECFMG sponsorship for clinical training and for ECFMG certification described earlier. Certain exceptions apply to physicians who are of national or international renown.
Information and Inquiries
ECFMG Certification and Sponsorship
Educational Commission for Foreign Medical Graduates
3624 Market St
Philadelphia, PA 19104-2685
F-1 Student Practical Training and J-1 Student Academic Training
NAFSA: Association of International Educators
1875 Connecticut Ave NW/Suite 1000
Washington, DC 20009-5728
H-1B, Lawful Permanent Resident Status, and Other Temporary Work Authorization
American Immigration Lawyers Association
1400 Eye St NW/Suite 1200
Washington, DC 20005