Many pathology residents are international medical graduates (IMGs) who join their residency on a J-1 visa. Doing so increases your fellowship opportunities because fewer programs support an H-1B visa for fellowships. Despite its initial advantages, a J-1 visa can be stressful after fellowship when looking for a "real" job. It is crucial to have a clear understanding of this cumbersome process early on in residency, preferably by PGY2, so that you can plan ahead of time and secure the best job opportunities.
A J-1 visa waiver job requires you to either work in a medically underserved/health professional shortage area for three years or to go back to your country for two years. Lots of employers either don’t understand or don’t want to deal with this tedious process. But while getting a good first job especially after a J-1 visa can be overwhelming and challenging, it’s not impossible by any means. You have already matched at a residency—congratulations! The hardest part of the whole process is now complete. Landing a job and finding a fellowship are far easier than finding a residency for IMGs. The good news for current trainees is that the job market for pathology has improved dramatically over the last few years and is expected to further improve,1 per several recent surveys and articles.
I completed two fellowships, one in general surgical pathology and the other in gastrointestinal and hepatopancreatobiliary pathology. I have been working at an academic institution for a little over one year. I started applying in the middle of my first fellowship and secured a job by the middle of my second fellowship year. Fortunately, I had a few offers from which I chose my current position. I gained some insight during the process and wanted to share the following tips with everyone who might find them helpful.
1. Take USMLE Step 3 as soon as possible and try to get an H-1B visa.
This first tip is for people applying for or already in the process of visa conversion. Reach out to the program directors during your interview and afterward regarding visa support. Once you have matched, reach out to the program again to make sure everything is in place for you to start on time. If you are on a J-2 or any other visa, convert to H-1B, if possible. During fellowship, try to go on an O-1 visa instead of converting to J-1. Basically, stay away from the J-1 visa if you can.
2. Assess the marketability of subspecialties before choosing.
You should, of course, try to get a fellowship in the subspecialty you love, but also consider whether it offers decent job opportunities. Talk to your mentors, junior faculty, and recent graduates to understand the current and potential future job market in your desired subspecialty early on in your residency. Use this information to make an informed choice, and do not apply to a fellowship because it is popular right now. Also, sign up on various job sites and watch the trends of the job market.
3. Start applying early and widely.
Do this preferably one year before your desired start date, and be flexible geographically. If you are restricted in this way, being proactive is especially important. See this list of J-1 job contacts for each state.
4. Reach out to confirm whether a job will sponsor your visa.
If you’re unable to confirm, apply anyway. Sometimes employers make exceptions if they’ve been searching for someone in your particular subspecialty for a while.
5. Know what kind of job you're looking for: academic vs private.
Reach out to the private groups or pathology department chairs well in advance, if you are restricted geographically.
6. Network, network, network!
Keep in touch with your fellow pathology graduates and others who were or are in a similar situation. Go to conferences and participate in national organizations such as the CAP, ASCP, and USCAP.
7. Understand the various J-1 waiver paths well in advance.
Many different programs allow IMGs on the J-1 visa to apply for a waiver of the two-year foreign residence requirement in exchange for working in health professional shortage areas. These programs include the Conrad 30 waiver program, the ARC J-1 Visa Waiver Program (for the Appalachian region), the Delta Doctors program, etc. The different paths are state and specialty specific and can play a very important role in starting your job.
8. Be receptive to extra responsibilities in your new job.
Have a strong base in residency. Use your electives in fellowships to broaden your experience, which might be helpful for your future practice.
9. Favor an employer who has dealt with J-1 waivers.
Once you have offers, you want an employer who knows what is expected from them. The paperwork is complicated and overwhelming, and an experienced employer who has a good lawyer is a blessing.
10. Build your CV during residency to be eligible for an O-1 visa.
The J-1 waiver may not work due to visa disapproval, etc. If this happens, you can always apply for a J-1 waiver in the next few years in the same or a different job after starting on the O-1.
Your residency and fellowships will soon be successfully completed; better times are in your future. Once you get a job, pay it forward and make sure you help your juniors and colleagues seeking J-1 waiver jobs. Good luck, everyone!
Feel free to contact me with any questions.
The J-1 classification (exchange visitors) is authorized for those who intend to participate in an approved program for the purpose of teaching, instructing or lecturing, studying, observing, conducting research, consulting, demonstrating special skills, receiving training, or to receive graduate medical education or training.
In carrying out the responsibilities of the Exchange Visitor Program, the Department of State designates public and private entities to act as exchange sponsors. J-1 nonimmigrants are therefore sponsored by an exchange program that is designated as such by the U.S. Department of State. These programs are designed to promote the interchange of persons, knowledge, and skills, in the fields of education, arts, and science.
H-1 B Classification
The H-1 B visa is a nonimmigrant classification that applies to people who wish to perform services in a specialty occupation, services of exceptional merit and ability relating to a Department of Defense cooperative research and development project, or services as a fashion model of distinguished merit or ability.
Health Professional Shortage Area
Designation as a health professional shortage area denotes a shortage of primary medical, dental, or mental health providers and can apply to geographic areas, populations, or facilities.
Conrad 30 Waiver Program
This program allows J-1 international medical graduates to apply for a waiver of the two-year foreign residence requirement upon completion of the J-1 exchange visitor program. (See section 214(l) of the Immigration Nationality Act). The program addresses the shortage of qualified doctors in medically underserved areas.
1. Gross, D. J., Black-Schaffer, W. S., Hoffman, R. D., Karcher, D. S., Estrada, E. L., Robboy, S. J., & Cohen, M. B. (2020). The state of the job market for pathologists: Evidence from the College of American Pathologists’ practice leader survey. Archives of Pathology & Laboratory Medicine, 144(4), 420-426.)
Neha Varshney, MD, FCAP, FASCP, is a new-in-practice GI and HPB staff pathologist and assistant professor at the University of Mississippi Medical Center. She has clinical and educational responsibilities in GI and HPB pathology and medical pathology. She is the author of numerous book chapters and articles and serves as an editorial board member for several journals. She is a member of the CAP New In Practice Committee and can be found on Twitter @neha_varshney.