Thank you for joining us today. My name is Vishal Madan, and I'm the Chief of Education and Deputy Medical Director here at the APA. I have the honor and pleasure of having two distinguished presenters with me, Dr. William Pinsky and Ms. Lucy Magrdechian. I'm going to go over a quick brief bios for them. So Professor William Pinsky is CEO of IntHealth, which actually includes ECFMG, and he's president of ECFMG, which is the Educational Commission for Foreign Medical Graduates. Before joining ECFMG, Professor Pinsky was Executive Vice President and Chief Academic Officer of Osner Health. This keeps moving. And then he also had a senior executive and academic positions at Wayne State University in the past. Thank you so much for joining us. He's a fellow of the American Academy of Pediatrics, American College of Cardiology, and American College of Chest Physicians. So thank you, Dr. Pinsky, for joining. Next I would like to introduce Ms. Lucy Magrdechian. Ms. Magrdechian comes from a diverse immigration law background, having practiced immigration law for more than a decade and a half, and owns her practice, Magrdechian Law, PLLC, in New York. She completed her JD at the New York Law School, and her expertise with the visa processes have helped countless IMG physicians over the years. We worked closely together to put some presentations at both the program director's organization and with the APA IMG caucus. So over time, she has been a true ally of our caucuses and truly been an outstanding resource for practical knowledge for us all. So incredibly grateful to you both. At the conclusion of this session, we are hoping that participants will be able to appraise the importance and contributions of IMGs in psychiatry in the U.S. and understand, obviously, the unique challenges that lie ahead for international medical graduates, both in terms of regulatory and legal challenges, and also hoping to get a peek into the future from both of you regarding both the regulatory as well as the legal issues. Now as we all know, when IMGs come over, you know, apart from the remarkable learning experiences that they carry, they also have to deeply familiarize themselves with not only the regulatory but also the legal aspects. And knowing how residency is so easy to do, right, and add to that, it creates a really needs a super person or super human to work together all of these areas. So how we are going to cover today, I'm just going through a brief introduction. I'll take a few minutes to talk about the contributions of IMGs and the unique and significant role that they play in delivery of mental health services in the U.S. And I'm thankful to the APA Foundation for working with all the MER groups to create this learning session. I will be followed by Professor Pinsky, who will be talking about the regulatory perspectives from the ECFMG standpoint. And following that, we'll have a legal perspective, of course, with Ms. Magradishian. And we'll have plenty of time. I do have some questions prepared, but it'd be nice if, you know, people can bring other questions that are practical and that there are potentially need answers to or struggling with. So without further delay, I will talk a little bit about some of our luminaries in psychiatry over the years. The first picture, as some of you may know, is Adolf Meyer, one of the biggest proponents of neurobiology of psychiatry. And the next picture is actually George Tarjan. And he was a luminary in psychiatry, and we have an award named after him. He was one of our first IMG presidents of the organizations. Jambur Anant is next. And again, a big name from India, who truly wrote about psychopharmacology and culture put together, giving a different definition to how things work out. Prakash Desai, another leading light from Chicago, who talked about psychotherapy and international medical graduates. And the recently deceased Pedro Ruiz, who was also a big proponent of IMGs and, you know, a legend in his own right. And some of the other living luminaries and IMG stalwarts who've either led our specialty organizations or subspecialty organizations or have contributed significantly to our understanding of IMG issues. You can see all Dr. Dilip Jeste, Dr. Paramjeet Joshi as ACAP former president for the Child Psychiatry Organization, Ike Ahmed for geriatrics, Ramarao Gogineni for social psychiatry, Rajesh Tampi for geriatrics as well. Then you have Dr. Raghu Rao. Dr. Pinsky might be familiar with him, having worked all those years with him. A huge name in psychiatry and IMGs. Dr. Francis Liu. So we have the Rao and Liu Fellowship named after both of them at the Program Directors Organization. Then Dr. Vishwanathan, who's our incoming president-elect. And then Dr. Renato Alarcon, who's a personal mentor and he's a professor emeritus at Mayo Clinic. And lastly, I think, and most importantly, is the empty picture frame, which actually looks at and defines all the public psychiatry IMGs that work so hard and putting together everything for our system, both in public psychiatry as well as in the underserved areas. So I wanted to dedicate this picture frame to them and the contributions that are often unrecognized, but they're so critical. Thank you. And as we switch our attention to the very alarming trends for international medical graduates, I'm sorry this thing keeps moving for some reason. As we think through and think about the total number of applicants for IMGs, you can see a very disturbing trend here from, it used to be around 30% of our PGY-1 in psychiatry in 2013 were IMGs. Now that number is around 15% and only around 6.9% of those are non-US IMGs. But also you can see the, actually the applicant numbers or the applications have gone significantly down. And you can see in 2000, even in 2021, they were close to, I believe, 2,500 and they've gone down to 2,000. Sorry, this, like I said, it keeps moving for some reason. And even in 2023, the numbers have gone down 500 more, so that's 1,600. So people are seeing the challenges that they come across and obviously they're disheartened or looking at other countries or knowing some of the visa challenges that people have faced or with the growing number of DO schools, like we've talked in other forum lectures, all of that is contributing to it. And again, this points to the average number of IMG applicants per psychiatry program. So it was around 800 five years ago, now it's around 400. So again, talking about the same issue that we are mentioning, how the number of applicants has actually gone down because of the changes in trends. Now this is reflective of how competitive psychiatry has been lately. You can see the average number of applicants for USMDs actually has gone up from 38 to 53 in the past five years. The IMG average number has gone up from 47 to 55. So both of them have gone up. And the reason for that is so many more people are applying and it basically takes away all the interview spots because more people are applying and they're getting interviews early on and there's not much left for the IMGs. This is a paper that was published last year and I know Dr. Pinsky, you were one of the co-authors for this. And this talks about the NRMP match and again, you can look at those numbers from 22 was 9.2% of US IMGs and around 6.5. So it's kind of stayed at that 15, 16% mark this year as well. And it's again, as I mentioned before, the other big challenge is how many of them remain unmatched. You can see around close to 50, 55% of them end up unmatched, which is a huge concern and what to do with them as we were discussing in some of the other talks. Another big issue with that is knowing our subspecialties, a lot of them are overrepresented by international medical graduates. And as you can see the numbers of like if the pipeline is tight enough and there's this huge bottleneck that's going to have a downstream effect on all the fellowship numbers that we are struggling with. So child psychiatry, for example, which is our best filling specialty that I would say around close to 50, 55% are IMGs and again, over the next five years, we'll continue to see such a declining trend as we are seeing from 2020 on. And not only again, not only are we concerned about the pipeline, but also I wanted to state again that the US psychiatry workforce as such. You can see in the fourth row, around 30% of all IMGs represent the overall psychiatry workforce and the other piece to know is there's an increasing trend of a lot of psychiatrists retiring in the next decade. So if we are constricting our pipeline, there's retirements happening on the other end. All the public psychiatry coverage that we have right now and sort of is taken for granted at times, we will run into huge psychiatry workforce issues. And lastly, why bother? And it's exactly for those reasons, like I was mentioning, but also wanted to say something as to how IMGs bring in a lot of resilience, a lot of maturity, a lot of experience, having been through so many bureaucratic hassles, come out alive and kicking and surviving in the system. It's really critical, again, often bring in research experience as well. And so it's really critical to keep a mature pipeline, to ensure they don't keep hitting the ceilings and not only training, but also academia and promotions at multiple levels. With that, I'm going to stop and I'm going to hand it over to Dr. Pinsky, who is going to talk about ECFMG regulatory perspectives. Please welcome Dr. Pinsky. Thank you. I just, while we're working on the computer, computer doesn't have the same resilience that IMGs have, so we've got a problem. But I'll add another prominent psychiatrist IMG to your list is Dr. Peter Buckley, who is also on my board, along with Dr. Rao. And Peter is a former dean, both in Georgia and at VCU, and is currently the Chancellor of Health Sciences in Tennessee. I've had the good fortune of writing on some medical reports. Yeah. So, it is an honor to be here today, and I almost always will go anywhere to talk about international medical graduates. I've been CEO at ECFMG, now Intel, for seven years, and during the seven years, I have developed a significant passion for international medical graduates, and the value that they bring to this country, and the value they bring back to their home country, as well. I'm going to get into the discussion about resilience a little bit as I talked. I think this is advancing slides still as well, but that's all right. Eat someone else on the same panel. So what I'm going to cover today is talk a little bit about our certification program. I know everybody's aware of it, but just to remind you of some particulars with it. I've got IMG trends and data as well. It's interesting looking at the psychiatry data that Vishal just showed. Our overall application numbers for IMGs continues to go up. And so it may be more of an issue in terms of who's looking at psychiatry versus the other specialties. But we'll talk about that. Something that's really important in terms of understanding the quality that international medical graduates bring is the issue of accreditation of medical schools around the world, and we'll talk about that. And then we've done a lot of work in the last seven years around the challenges facing particularly foreign national IMGs as they transition to this country. And I'll cover some of the mitigation and particularly our advocacy efforts, which are significant. So Intel may not be a name that is familiar to you. When I joined ECFMG seven years ago as CEO, it became apparent to me that both ECFMG and FAMER, do you all know about FAMER? A few nods of heads there. FAMER is a subsidiary or was a subsidiary 501c3 of ECFMG, it's a foundation for the advancement of international medical education and research and basically works around the world through their institutes to train the trainers, to train the educators, faculty development, as well as do research. And up until two weeks ago, in addition to serving as president and CEO of ECFMG, I was chair of the board of FAMER. Now we have a single corporation called Intel with each one a subsidiary or a division within Intel. And it just makes a lot of sense from an operational and a governance perspective. But it's important because it does reflect the transformation that we've been doing the last seven years of combining efforts and trying to get the most out of working together from an ECFMG and FAMER perspective. I'll mention this a little bit more, but also I'm happy to answer more questions about that afterwards. So this is our current structure. Intel now is the corporation. We transferred ECFMG's 501c3 corporation to Intel. So we continue to be a tax-exempt organization with ECFMG and FAMER as the two main operating divisions. ECFMG serves as evaluating qualifications of physicians worldwide, not just for international graduates coming to the United States, but for two dozen countries around the world, we do the same thing. And then FAMER, as I talked about earlier, supports health professions through educational programs and research. So Intel now combines ECFMG and FAMER together under a common vision. Our missions are synergistic. ECFMG and FAMER, though, still have their same portfolio of services. And I talk about it today, which maybe is a little bit off topic, but it's something you're going to hear more and more about as time goes on, really trying to help people understand who we are going forward. ECFMG is continuing its certification process, primarily for international medical graduates coming to this country who are applying for GME positions. As I mentioned a little earlier, we work with over two dozen regulatory agencies around the world. Prominent ones include the General Medical Council in the UK, Canadian Medical Council, Australian Medical Council, New Zealand, South Africa, many other countries in Africa where we do the similar thing. FAMER has its activities in the education area. We just opened up our 12th FAMER Institute around the world. A few weeks ago, we opened this up in Uganda, in these 12 institutes around the world. And actually, there are thousands of graduates. The institute, or FAMER, is 23 years old. We have thousands of fellow graduates around the world who are now prominent in medical school leadership positions around the world. In fact, I have a tree that I planted in Manipal, in India, at the institute there. So if anybody's going to visit Manipal in the future, look for my tree. It's in front of the engineering building for some reason. I have pictures, too. So we've been doing our certification for 70 years. The history of why we exist is, after World War II, there was a big influx of physicians, as you might imagine, into the United States, probably mostly from Europe, Eastern Europe in particular. And a question came up, who are these people? Are they really doctors? What are they capable of doing? And ECFMG was formed to do that. Over the last almost 70 years, how we do it has evolved. Our real, probably, intellectual property is our primary source verification. So we can identify that the person is who they say they are, they're not their cousin, that they did graduate from a medical school, they do have a diploma, we do have a copy of the curriculum that went through there. Obviously, there are exams individuals have to take. In recent years, it's just been the USMLE exam. As we've partnered with USMLE, there used to be, and anybody older in the audience who came through decades ago as an IMG would know, we used to have our own exams, but now it's just the USMLE, I shouldn't say just, it's the USMLE exams. Currently, and this gets into the regulatory part of the talk in terms of who is eligible for ECFMG certification, number one, the medical school has to meet our requirements. Currently, the requirement for the medical school is that it's licensed in its country and that graduates of that school in that country are eligible to receive a medical license in that country. That's a really key component of the medical school. The medical school curriculum needs to be something comparable to the curriculum in the United States. Not talking about accreditation yet, but comparable. There are issues, and I think that this scenario is improving in China, for example. If anybody's familiar with medical schools in China, there's the classic Chinese medicine curriculum and then there's more of the medical curriculum that we're used to. We have to be careful in terms of where they come from there. An applicant needs to pass step one and step two, CK, of the USMLE exam. Needs to be also to pass clinical skills exam. Clinical skills exam went away with COVID, and as it went away with COVID, we were still very concerned about having appropriate ways of certifying individuals for supervised care. We developed what we call our pathways, six pathways, as well as passing an English language. It's not a language. It's a care model and ability to communicate. It's really a communication test with OET. It stands for Occupational English Test. It has been developed by Cambridge University in the UK. As I said before, of course, we have to primary source their diploma and transcripts. We work with three guiding principles, and these are really very important. Number one is to assure the public that individuals who are certified are appropriate to be involved in supervised care. We are not certifying individuals to go directly into practice. Every licensing board in the United States has statutes that would preclude that. We're certifying them to be in supervised care. We also are committed to assure program directors that they will have a robust cadre of individuals from which to choose. And then finally, just as important, we're here to facilitate international medical graduates being able to pursue their professional development. I am sure that international graduates sometimes think that we have too many hoops out there that they have to jump through. And I know it's arduous. And what we do, though, is through this process, we're facilitating their opportunities to be able to come here. If we were not doing this, then there would be no opportunity for them to be here. There's still about 25% of practicing physicians in the United States graduated from outside of the United States and Canada, so somewhere around 240,000 international graduates practicing. Vishnu was talking about the resilience and the arduous route to get to us. We received probably, this was true pre-COVID, we had a dip early in COVID. Now the numbers are continuing to climb. Over 20,000 letters of interest every year for certification. And we probably have actively over 16,000 who were in process for certification. So the United States, even with all of our crazy politics and other things going on in the country, still is a valued site for residency. And as you know, as individuals progress through the certification process, then we are able to enroll them in EROS for the match. And then we are the only agency that the United States Department of State authorizes to sponsor J-1 visas for physicians and J-2 visas for their families. So overall, for international medical graduates in the match in 2023, this past March, almost 8,400 matched into first-year positions, which is not quite a 10% increase over the prior year. And you can see on the slide the progression from year before COVID, the year COVID came out, and then up until this current year. So while we did have a dip in 22, which I probably think reflects some lack of progress from individuals during COVID, the numbers are back up, and I can tell you through the first quarter of this year, the numbers have still gone up even further in terms of applications for certification. And I'm imagining in terms of EROS tokens and applications as well. There continues to be a growth of U.S. IMGs, with 257 additional matched this year, but that's still less than the international graduates where there is an additional 461 compared to the prior year. So I think you probably covered this slide, Vishnu, but I just wanted to demonstrate psychiatry. And we've noticed a fall-off in applications in psychiatry as well. And so it would be an interesting discussion at some point in terms of since the IMG numbers continue to climb, why not psychiatry? And which you wonder in terms of what people are hearing, learning, and thinking about. Here you can see the various specialty match from this prior year. Internal medicine still continues to lead the match, still over half, probably almost 60% of all PGY-1 positions in internal medicine are filled by IMGs. I always find that astounding, and it continues to climb by a little bit every year. Family medicine, pediatrics, emergency medicine this year is interesting. I don't know if you all are aware, emergency medicine in the match had a huge number of unfilled positions. And many of those match positions were IMGs. Many of the unfilled positions were eventually filled by IMGs. And so we could get into a discussion of emergency medicine, politics, Dobbs Act or Dobbs decision, all sorts of things in terms of why all of a sudden emergency medicine was not popular with applicants. Some of you may have heard about our medical school accreditation policy. Preceding my arrival at ECFMG in 2010, the ECFMG board passed a resolution that by 2023, ECFMG would only accept applications from graduates of accredited medical schools. What prompted that was the huge proliferation of medical schools around the world. Close to home, there was a huge proliferation in the Caribbean. But it's true, Mexico doubled the number of schools. India has had a massive increase in the number of medical schools. China did as well. And so the board was concerned with this proliferation of medical schools. How do we know that they're being established and accomplished and what was supposed to be accomplished? We're comfortable, I think, in this country with the LCME and the accreditation. And I recognize in the U.S. we probably are overregulated in many respects. But the LCME accreditation gives us a lot of comfort in terms of the type of education people are getting. And so that's why they passed that resolution. Of course, with COVID, we've moved the deadline, and I'll talk about that on the next slide. When I joined ECFMG seven years ago and really learned more about this accreditation resolution, I recognized that the reason the board did it, and it was for very U.S.-centric reasons, for the reasons I just talked about. But what I came to realize very quickly as I traveled around the world and talked to accreditation agencies, educators in medical schools around the world, is that many places were looking forward to having an accreditation for their medical schools as a way to increase the quality of the medical education, which I recognize is one variable that can increase health care, quality of health care in their countries. And so even though the board recommended this for a certain reason, I really think not the secondary reason, but the secondary effect, the primary effect has been to boost medical school education around the world through education. Of course, if you remember, one of my very important guidelines for us in terms of guiding light for certification is to assure the public of the individuals, and that's something that's really important. Two minutes. How long? Two. I'm going to have to talk fast. Don't I get some time back for the computer? We are happy to, if you have time, we are good. Just kidding. So today we have recognized accreditation policy that what was passed by the board in 2023 could not be implemented in 23 because of COVID. We've moved it to 24, but we've changed it for a variety of reasons. We will continue to accept applications for certification from everybody who applies, who meets the requirements to apply. And instead of denying them the opportunity, we're going to give them the opportunity, give program directors the opportunity to still choose people who are coming from a non-accredited school or a school where the accrediting agency is not recognized. And we're going to publish the data in the World Directory of Medical Schools and in the individual's ERAS application for residency so program directors can decide. So if a program director has always accepted somebody from a certain school and for whatever reason that school is not accredited in the way that we've recommended, they can still accept them if they wish. I think it's fair to applicants. What we're saying is with the policy the school is accredited, the accrediting agency that has done that work needs to be recognized by an organization that says that it's doing what it's supposed to do. The World Federation of Medical Education in Geneva, Switzerland, is the primary one that has done the recognition. The National Committee on Foreign Medical Education and Accreditation, NICFMEA, which is part of the U.S. Department of Education and oversees the Title IV funds that U.S. students can apply for for medical school is the other one. A quick look at this map will show you the disbursement around the country of those countries that are accredited and those that are in process. So we think that this initial implementation will meet the goals of what the board had asked us to do. Just talk a little bit real quickly about challenges for international medical graduates. Discontinuation of Step 2 CS could be a challenge. Actually, we're thinking the fact that they don't have to get a visa to come to the United States to take CS is one reason why we're getting more applications for this. Clearly, Step 1, transitioning to pass-fail, is a hit to international medical graduates who would use this exam to differentiate themselves. And obviously, the number of increasing allopathic and mostly osteopathic medical schools are a challenge to them. IMGs have some distinct well-being issues that, it's just more information about the exam, well-being challenges compared to U.S. You know, we have continued to do surveys with our J-1 physicians. Almost 30% of the physicians have no spouse or partner or immediate family in the United States, which can be a problem. Over 10% don't feel connected in the communities. And a significant number, 5% is significant, do not have some people that they can talk to when they have issues. So we put a lot of support functions in place, administrative, working with programs to help improve financial issues. You can't get a bank account or a cell phone if you don't have a social security number, helping with that and helping people transition. We're launching a pilot next month, an electronic medical record pilot for international medical graduates who have matched so that they can go into their programs with some practice on the electronic record, because many countries where they're coming from will not have had an electronic record. A big part of my job the last seven years that I started that UCFMG had never done before is advocacy for international medical graduates, particularly politically. We have a wonderful relationship with the Department of State. We were responsible for the opening of consulates and embassies around the world when COVID was announced in March right after the match and all the embassies and consulates closed. And we had a very excellent success rate of getting international medical graduates here. We continue to go to Washington. We continue to go to states around the country to be able to speak for international medical graduates. And this is why we're very optimistic about the future of international medical graduates overall. They're very important in this country. We're getting the message out in terms of why they're important. And that's one of the reasons why I'm here today, because I want all the specialties to know how much we support this. And I'll stop. Thank you so much. Thank you. Thank you, Dr. Pinsky. Pleasure to have you. We will hold the questions till the end for a little panel discussion. Next up we have Ms. Lucy Magadishin, I hope I can hold her slides. Good afternoon everyone, it's an honor and privilege to be here, thank you Dr. Madan for inviting me, this is my third time presenting at this conference, and immigration has certainly posed challenges, I think more so now post-COVID, with severe backlogs, and with the consulates being closed, and you know, having to prioritize positions, and I get daily calls, people don't want to travel, because there are all kinds of issues, but there are also certainly challenges in the United States with immigration, so most of the programs, residency and fellowships now are on J-1, they sponsor J-1s, and J-1s are limited, as Dr. Pinsky already explained, you know, the whole ESFMG certifications, the J-1s are being sponsored through ESFMG. The duration is for seven years, and that usually covers most specialties, for residence and fellowships thereafter. However, the J-1s, clinical J-1s carry a two-year foreign residency requirement, which requires the physician to go back home, unless they choose to do a waiver, and I'll discuss several ways to do waivers. Just put a little chart here. I'm not sure if there are any programs that still sponsor H-1Bs, but if you're one of those lucky IMGs in an H-1B residency and fellowship program, you know, it certainly poses limitations, because those programs are exempt from the annual 65,000 H-1B cap, or additional 20,000 for U.S. master graduates, and there's a requirement such as paying certain salary, and, you know, while it's good if you come out of a residency program, it becomes challenging if you want to work for a private employer, because the H-1B are cap-exempt, and you cannot go from a cap-exempt institution into a private employer. You still have to find an employer that could give you the opportunity to work in an academic setting in order to continue the H-1B exemption. There's several ways to get a waiver if you're a J-1, so you finish your residency or fellowship, and the types of waivers that one can apply is either hardship, persecution, or interest at government agency. The most popular one out of the IGAs is the Conrad State 30, and Department of Health and Human Services, HHS. They are taking now pretty much all general psychiatrists, and a lot of states have gone away, because a lot of the states have 30 slots available per year for J-1 waiver doctors. HHS, they're pushing all the general primary care and general psychiatry onto HHS now, so that's a relief, because if you're a specialist, you could get a slot now with the state. The other type of waiver, hardship waiver, there are certainly challenges now, and a colleague recently told me that they're seeing more and more unfavorable decisions by Department of State, and hopefully that's something that would be reversed, but not only is it challenging and they're issuing unfavorable decisions, but they're taking over 12 months to even get a decision out of USCIS and Department of State. I have outlined the criteria for exceptional hardship, such as economic, political, religious, environmental, psychological hardships, usually to a family member, U.S. family member, such as a child or a U.S. spouse. There's another waiver, persecution waiver. It's similar to asylum. It's usually for a J-1 physician that doesn't have a U.S. family, and it can meet the criteria for a persecution waiver. I'll go more in depth with the state, the interest of government agency waiver. There's the state, which authorizes the Conrad State 30s, the VA, Department of Veterans Affairs is another one that you could do a waiver, but I believe not all VAs, they prefer to take U.S. citizens now, so I'm not entirely sure these days they take foreign graduates. If they take IMGs, there are certain VAs that were taking IMGs, so that depends. Then, depending on if certain states fall within the Appalachian Regional Commission and the Delta Regional Authority, they also sponsor waivers, and of course, HHS. The process for a Conrad State 30 waiver, it has to be in a medically underserved employment site, has to be medically underserved or health professional shortage area, or for psychiatrists, it has to be a mental health professional shortage area. Each state has its own guidelines and deadlines and requirements. The recommendation is to start a year, one year before graduation, so you have enough time to transition from residency into the waiver. As I said, HHS issues primary care and general psychiatry waivers, and there's no limit to that, so you will be in luck getting a waiver. If you don't do it through the state, you could do it through HHS. Then, certain states have flex-home slots, there are usually 10 of them, but I think because HHS opened up, there's probably states do take specialists more so now. As I mentioned, each state have their own requirements, and what usually is the application process starts in the fall. It does require a little bit of work on the part of the employer. They have to advertise for the position, you have to apply for a license, the application for a license has to be in place before filing the waiver, but with every state, it's a little different, so the state guidelines need to be followed. The employment is for three years, for 40 hours per week, in an underserved area. During COVID, there was a welcome change for telemedicine that allowed doctors to work remotely through telemedicine as part of the 40 hours per week. However, now the national emergency ended, we're yet to see if they will keep telemedicine. I think this was important, especially in psychiatry, and I think it was something that was very good for patients, especially because I have my psychiatry clients have told me they're extremely busy, so hopefully USCIS will keep this change, we're yet to see. No announcement has been made as of today. The way it works with the waivers is first, you apply either through HHS or through the state. Once the state approves the waiver, they send it over to the Department of State. Department of State has to approve the waiver and then send it to immigration for final approval. Then usually that happens if the application process is in the fall, you get the approval in the springtime, and then you move forward and change to H-1B. All waivers must be complete in H-1B status, so you work three years in H-1B status. Changing employers is extremely difficult on a Conrad waiver unless they're extenuating circumstances. The application needs to be made to immigration with evidence of the extenuating circumstances. It's important when you choose your employer, it's a little difficult in the beginning to tell whether or not it's going to work out, but I've heard a lot of horror stories where employers have made doctors work crazy hours, prescribe medications, pressure them to prescribe medications that the doctor doesn't feel comfortable. These are the types of extenuating circumstances that can be shown to immigration why they cannot continue the waiver with this particular employer. Then this is a little chart, also the little comparison just so you know as to the type of waivers and what's required, and the Delta and Appalachian, they list the states. I think for the most part, the HHS, the clinical HHS waiver and the Conrad State 30 are the most popular one. I have seen Delta and I've seen Appalachian, but again, there's a different requirement for each. Changing status from J-1 to another non-immigrant status is generally not allowed unless you're doing an H-1B, or you're going to do the H-1B Conrad State 30, or interested government agency waiver. For example, if you had gotten a hardship waiver, then you subject yourself to the annual cap, unless there's a cap exemption. This is also if you can't go from an O-1, from J-1 to an O-1, and also can't go and simultaneously file a national interest waiver, petition for a physician working for five years in an undisturbed area. For Canadian IMGs, they could go and own an H-1B before even obtaining a waiver, because Canadians are exempt from a visa requirement, and a lot of them also choose to commute. If you're Canadian and you can commute and have a home in Canada, then you could count the time staying in Canada toward your two-year foreign residency requirement. I've seen that for Canadians, and a lot of them do it this way. Let me do a little backwards, too. The IMGs that are on J-1 and have a spouse on a J-2, the J-2s are allowed to work as well. They get employment authorization. If there's two spouses that are physicians, they can both do their residency and fellowships, one in J-1, one in J-2, with employment authorization. However, the J-2 also is subject to the foreign residency requirement, and the J-1 primary applicant will have to apply for a waiver, and then the spouse, the J-2 spouse, would get the waiver as well. J-2s cannot change status to H-1B directly. First, they have to go on an H-4, dependent visa, before going to H-1B. If a foreign medical graduate does a Conrad waiver, and they can switch to H-1B and the spouse goes on H-4, but then the spouse has an offer of employment, the spouse has to go from H-4 to H-1B. It gets very complicated. You have to work with an immigration lawyer to explain all of this. It could certainly make your head spin. Okay, okay, so one alternative especially sometimes timing doesn't work right and you know you run out of you're done with your residency or fellowship you run out of Jade time you couldn't get a waiver or one becomes an alternative to to you know sort of postponing your waiver and but not everybody qualifies for an O1 the O1 has a strict requirement and it's you know if you're in academia if you are in residency and fellowships I always advise for an IMG's is get involved do research try to publish just so you could position yourselves in case the O1 and later on you know a little slides down I'll talk about the green card options so you know it's it's important to start early to build up on your CV so you could take advantage later on if you're in a situation where you know H-1B doesn't work and O1 becomes an option so there are few ways to get a green card which has become somewhat challenging these days even during COVID in from Jade you have to in order to get the actual physical green card you have to finish your waiver obligations first the only way you could start the green card process but you cannot apply for a final step, which is the I-485 Adjustment of Status until the waiver is complete. The only exception is if you filed a National Interest Waiver Physician case working for five years in an underserved area, then you could file the I-485 concurrently. I put here it's beneficial if the spouse needs authorization, but employment authorizations these days take a very long time. Unfortunately, they're not even prioritizing doctor cases, and I've put none of my expedited requests for doctors have been approved. That tells you how functioning the immigration system has become. They do allow employment authorization extensions for doctors, but not initial employment authorizations. I also get a lot of questions, I want to file an I-485 to get a travel document. Yes, wonderful, travel documents take 14 plus months, so that is also not something that ... It's not beneficial in a way, so talk to your ... It's something every application needs to be ... Green card application pathways should be discussed with an immigration attorney, so that way you could be advised of what's the best option. We have ... The way you get green cards is either through family-based petitions or employment-based petitions. The quickest route to a green card at the moment is if you're married through spouse, or through spouse who's a U.S. citizen, LPRs are taking a little longer. The other pathways are employment-based, and depending on the physician's credentials, they could either do EB-1, employment-based, or EB-2, national interest. Of course, the last one would be labor certification form through employment-based. I'm outlining here the EB-1 criteria. This is the most difficult one to obtain. It's very similar to the O-1, except that you have to really demonstrate extraordinary ability, and really, immigration is really big on publications, on citations, on scholarly work, on inventing certain medical modalities, or treating patients a certain way. Not everybody satisfies this criteria. It's very subjective, and there's usually a big percentage of denial under this category. The other pathway is for somebody that's in academia, usually for outstanding researcher and professor. It is similar to the EB-1, but you have to show the applicant have at least three years of experience in either teaching or research in an academic field. For professor, it has to be a tenure or tenure-track position, and there has to be an offer of employment for a permanent position. The second pathway will be national interest waiver, which I briefly mentioned about working for five years in an underserved area. It's self-sponsored. You don't need to have an employer, but you must have an employment contract, and you must work for five years. It doesn't have to be five consecutive years. It could be one year or two years break, and then go back and finish the requirement. Three year, if you're doing a J-1 waiver, the three years count toward the five years. For some physicians, that's a really good pathway to get a green card. It's minimal work, and it really is an easy way, especially if you know you're going to work for five years in an underserved area. It's a good pathway. Of course, you cannot get the final physical green card in your hand until you finish the five-year requirement. Then there's the EB-2 National Interest Waiver based on the Danisar decision. This is also not a good pathway because the standard has been lowered. The key is pretty much the first prong, the foreign nationals' proposed endeavor has both substantial merit and national importance. That pretty much goes with the credentials like publications, presentations, in the medical field, what kind of additional research you're doing that's going to help this country. The other two prongs are generally satisfied pretty quickly because we showed the degree and the wide labor certification employment is not required. The final pathway is through employment-based sponsorship. This is going to become extremely challenging now because the form that we used to complete and file this online has changed. We're yet to see how cases are going to be reviewed. This category is very ... In a way, it takes two years to get the green card. It has slowed down tremendously just because there's certain steps into the Department of Labor involvement and then the USCIS involvement. For physicians, the key is you have to have all your credentials and your license before the application gets filed. If you work for a small medical practice, then the financial ability to pay the salary becomes an issue. Again, it's something that needs to be examined with an attorney to see if this is the safest route to go. Usually, this PERM has been the safest route, it's just that it takes the longest. Then these are just the comparisons between the EB-1, EB-2, sole-sponsored, the five-year, NIW, HPSA, and the employment-based sponsorship. Just because the prevailing wager loan right now takes about nine months and then takes about two months for advertisement and another nine months for a decision out of Department of Labor. It's certainly a long time. That's where I'm going to stop. Thank you very much, Ms. Magradechian. I'll request Dr. Pinsky to join the panel here. Since the session is being recorded, I'd appreciate if you all can go to the mics with any questions. I'm going to ask Dr. Pinsky to join the panel here. Since the session is being recorded, I'd appreciate if you all can go to the mics with any questions. If anyone has questions, or I definitely have a few, so please go ahead. Thank you. I'm just going to adjust this. Hello. I'm Jorge Sanchez. I'm a research associate. I'm a Mexican-trained psychiatrist. I really appreciate the opportunity to have stakeholders from all walks of the IMG life here present at the APA and giving us their view and showing us their expertise on the matter. I really do appreciate it. So thank you. So I hope I don't, I mean, I'll take turns, but I have a couple of questions. My first question is, what is Intel's position on internationally-trained specialists? And if any thought has been given to adapting the pathways for internationally-trained specialists? So I probably need you to clarify your question a little bit. When you mean pathways to come directly in without doing residency? Well, not really specifically, but rather to redo the residency. So it's a complicated system, I think, much more complicated for specialists, given that it varies a lot by specialist board. The ABPN is only certifying US and Canada-trained psychiatrists. So I think the only way for us internationally-trained psychiatrists to practice here in a safe way, I think, is to redo residency. Yeah. Right. So we're very supportive of all specialists. It doesn't necessarily need to be primary care physicians. Our role is to accept applications from anybody that meets the criteria that I mentioned before and to be processed accordingly. It's interesting, the question about doing residency in the United States, the heterogeneity of medical schools around the country is significant. The heterogeneity of postgraduate training is even greater, which is sort of interesting. The statutes in the 50 states that require one to three years of GME training before an individual can receive an unrestricted license, it's not our policy, it's theirs. Actually, I just learned today there's a bill, I think in Tennessee, I can't remember right now, to preclude the training. I'm sort of agnostic, officially, I'm sort of agnostic on the training part, but I do believe it's important to be certified with primary source verification. My personal feeling is, it's like what you just said, is that the training is heterogeneous enough around the world that it really is a benefit to do some training in this country as well. Yeah. I can add a few things. I think what you're trying to refer to is also for individuals who are already trained in psychiatry in their home country, and they have to come back, and there's the same pathway that you have to undergo, even if you may have been a faculty in your home country. I think there are specific specialties, and there's probably close to a dozen that have alternate IMG pathways that have been created, especially I can think of radiology and maybe even anesthesiology, and psychiatry hasn't done that over time. That's ongoing discussion, and part of it is because our subspecialty spots do not fill as well, and our primary, the residency spots in the past four or five years have filled like 99% right away, right? So you're left with very minimal number of spots that go unmatched. And so the discussion is whether we can bring in a potentially trained individual in psychiatry, and can they join as a fellow, potentially, right? Do that fellowship, become US-trained as in that fellowship, gain clinical experience, and then apply for residency in psychiatry. So there's no running away from the psychiatry, general psychiatry, because that's definitely there. So ACGME does have a little clause there that allows an exceptional international individual to go through that pathway, but it's very limited as in, I've heard of maybe two or three programs trying it. What you need is an approval from the training director, from the chair, from the DIO. And part of why this is a challenge is because state laws, you know, if you can't practice or get a license, then there's no point of doing it. So what Dr. Pinsky was referring to is a provisional license piece that's come out in the state of Tennessee five or six days ago. So there are openings there. We are having conversations with our board, the American Board of Psychiatry and Neurology, to see if something of that is a possibility. So stay tuned. Thank you. Thank you very much. And I just have a minimal follow-up question that kind of ties into this. So given that the Step 2 CS has been discontinued, and now pathways are the only way for IMGs to be certified, the caveat is that pathways expire. So I'm kind of interested as well in what Intel's position is regarding the increasing the expiration date or providing a way for someone to get a non-expiring certificate. So we've been talking to some of my colleagues inside the office. This is a big debate going on right now with us. So the way the pathways were set up, that the ECFMG certification would become permanent upon successful completion of one year of GME, and that there would be a three-year opportunity to obtain that GME training so that it is not a permanent certification. The reason that when we started that it's not permanent is we felt that there needed to be some evidence of the actual clinical ability to do clinical work. So we're actually right now having an internal debate on what, you know, that we still believe to be permanent. It needs to have a year of GME. But is three years the right number of years for the temporary perspective of it? So the non-answer I have for you is that we're debating it. And probably before the end of the summer we'll know where we are with that. Thank you. Thank you. And I think it's especially important given the decreasing number of psychiatrists, IMGs, that are matching. I'll take another frame. Thank you. Hello. Hi. My name is Abhishek Alam. I'm a first-year PGY-1 resident at Tower Health Hospital in Pennsylvania. So I'm from psychiatry, so we're always concerned about the mental health of the IMGs regardless of speciality. And in our hospital group we have about 400 residents. And so I'm kind of like taking the initiative to look at IMG issues and try to help out the residents, whether transitioning into their first year or during their residency. So one of the issues that, you know, and all of us are on J-1 visa. We only sponsor J-1 at our institute. So J-1 is like, there's no like a three-year or four-year visa that is offered. It's like a yearly visa that we have to renew every year. And that creates, so I don't know if this issue has come up before, but it creates an issue with, you know, us visiting our families. Like every year when we go back to our home country, we have to, you know, do the visa stamping again. And also in terms of education, we are unable to apply to international conferences because our visas get expired after our first year of coming here. And so if you want to go to like say France or Paris to attend a conference or to publish a paper, we have to send our colleagues who are U.S. citizens for our own publications unless we go back from France to our home country to get stamped again and come back. So you don't have to leave the country to extend the visa every year. It's pretty much an automatic process. You know, it's a paperwork, but it's electronic. The application needs to be filled out and we have to have evidence that you have a contract for the next year. You don't have to leave the country to have anything. Absolutely. I understand that the process while we are in the U.S. is quite very seamless and don't have to leave as long as we are in the U.S. But anytime we leave the country and come back into the country, at that time at the port of entry they ask for stamping of your passport. And so that creates a kind of educational issue with having international publications and also like visiting family, you know, just in terms of well-being of IMGs. So I know the details in terms of J-1 visa work at about 15,000 foot level. Tracy Wolowitz on our staff is the one that is the expert in that. If you would send me an email. Absolutely. I think I know how to answer your question, but I don't want to say it the wrong way. So it's just wpinski at intel.org. And I'll get an answer for you right away. Absolutely. I really appreciate the session and really thankful for all of you to be here. Thank you so much. Thanks. Do you have something to say about that? Yeah. So it would be actually very beneficial if maybe ESF and G, knowing that it's a three-year program, perhaps get, you know, secure the contracts for the three years. So that way, or four year, whatever the residency is. And they issue one DS-2019 for that full period so they can get the visa. The problem, the reason it can't happen that way is ACGME contracts are yearly. And so we can't say they have the contract until they have the contract. You know, and the residency contracts are not issued for multiple years. And so that's why we need to have the contract. And it also means that we know where everybody is. Compared to other visa sponsors and visa categories, we've never misplaced a visa holder. And we don't want to start now, but that that's the complicating part of it. It's the stamping part that I'm not sure about. Well Department of State have agreed to renew certain visas in the United States, so you know it may be something that you can discuss with them. Can they do J-1s? They're starting a pilot program for H-1Bs, I believe, for IT professionals, but if they can do that for physicians and you're the best position probably to ask them if they're willing to do that. So that would take away a little bit of dealing with the consulates, although they're prioritizing J-1s, and you know I haven't heard anybody being stuck. I know the process is long, especially now with the with the way they do the waiver dropbox, waiver interview, waiver through dropbox. It can take a few weeks. I think it's it's that's where advocacy will be, you know, within ACGME, within ECFMG, and I think looking at the individual programs, because if the that's the other challenge, right, for ECFMG would be if an individual program doesn't say you're ready to move on to the PGY-2 year or whatever the year might be, you won't get a contract till then. So I think that's what he's referring to, where you know you run into this chicken is to egg sort of a situation. So where I always get confused, because I'm not an attorney, I'm not a visa expert, is the difference between visa status and having a visa. Right, that's confusing. The visa is basically the way I explain it. It's sort of your entry ticket to come to the U.S. So at the border you're given an I-94 number, which covers your stay in the U.S., and if you come in on a J-1, it's duration of stay. Right. So you could stay here and not travel, but the actual visa in the passport, sort of your ticket to the U.S., that has expiration date, and I'm sure they give it, if it's one year, it's one year, and every year it has to be renewed. I will say that we came close to a disaster, though, because there was a proposal on the duration of stay, that after every year of training, an individual is going to have to leave, go back to the country, and reapply, and if that had happened, given the lack of expediency in terms of processing, it would have shut down GMA, and we really pulled together all elements of the House of Medicine to counter that, and we're able to, it was signed at the end of the prior Trump administration, and we were able to get to Homeland Security, and basically they just didn't process it, because it was signed to be implemented at the end of 2020, I guess. I think that's where, again, all the organizations put together an effort led by ACFMG, and I know AMA, PA, Adpert, all of them signed on to the letters, too, because that would have been created a disaster, like he's mentioning, especially if you're switching over to a fellowship, then it was another big, big challenge there. So, I have one question for each of you, and then we'll go back to the audience. So, Dr. Pinsky, one of the, you know, you talked about the World Federation of Medical Education, the WFME process, there were a lot of countries either still in gray or not working on, right, so, and I know you have postponed that decision, I believe, from 2022 to 2023 and now to 2024, correct? But this, again, you know, if I am someone, if I'm a bureaucrat in a country, I would prefer not to get into some sort of approval process which allows my doctors to go to a different country. How are you navigating that? And second piece is, from our standpoint, does that create any issues related to diversity and equity, because, you know, if you're not having specific countries where the approval process is ready, or, you know, how do, how are we navigating that? Yeah, so, I'll answer the second part first. So, to maintain that diversity and to maintain the opportunity for the applicants and to maintain the program director's ability to make their own decisions is why we're saying when it's implemented in 24, it will not stop anybody from applying, but their record will indicate whether they've graduated from an accredited medical school and whether that accrediting agency has been recognized or not. That way, program directors can make their own decisions how they want to proceed. The first part of the question is really interesting, though, and, you know, a lot of people brought that up to me a few years ago, you know, and, in fact, in India, there was somebody in the national government that was quoted as saying, why would we want to get accredited and have our physicians leave? And I have spent hours and hours of in-person and remote conversations with leadership in India, just as an example, explaining what this really means in terms of the image of a country, and I'm not, it's not like I'm picking on India, but I'm really not, it's just that it's a great example, particularly a country that has such a long reputation of having excellent universities, particularly in the sciences, what it would look like if they were not able to have their accrediting agency recognized. And so, the reconstituted agency, the NMC, eventually has submitted and is in the process with WFME on the recognition. And even in countries in Africa, where there's been a lot of concern about brain drain and that sort of thing, they actually see the opportunities to use this to raise their standards for medical education. And tied to that, one of the questions I get frequently with, you know, with our sponsoring of the J-1 visa is, is what happens to these physicians? How many stay? How many go home? You know, you know, what, is there a brain drain? All those sorts of things. And it's difficult to answer for a couple reasons, one of which is, it seems that many individuals who have been on a J-1 visa don't just stay or go in one direction. So they may get a waiver and stay here, work for a while, go back home, still working here, go back, contribute in a variety of different ways back home, or eventually go back home. Likewise, the other way, people may leave for their two years outside the country, stay longer, and then come back. So we did a survey, excuse me, a few years ago, trying to find where, and I didn't bring that slide with me, but I'm happy to make it available, that shows, you know, where J-1 visas are and prior J-1 visa holders are. And there's actually a brain gain when you look at what people are doing back in their home countries from a medical education, research, and provider perspective. I'm glad you bring that up, because I think that's kind of what we've learned over time, is it's actually a brain gain is an even better term than reverse brain drain, as it's called. So that's even better. So thank you. Ms. Magadish in question about J-1 waivers in academic situations, because a lot of time, you know, you train your resident, and then you do not have an opportunity to create a J-1 waiver position. How do people in academia work on that so they don't lose their well-trained people? Well, there's, I didn't discuss it, but there's HHS waiver for researchers, but that's extremely difficult. You have to be pretty much brilliant to get that, because it's reviewed by peers, and it does take a long time. So it's, it depends on the physician's credentials, but it has to be somebody that's doing extensive research, and you know, the peers, the physicians, the peers are reviewing the application. So I can tell you, as a former program director in pediatric cardiology, before I ever got involved in this or even knew anything about how all this worked, we were able to get Conrad waivers and had individuals work in some of our outreach clinics in underserved areas for enough of the time where they could still be doing their research and teaching as well. So I think in some academic situations, they're able to work through it. I think it's, it's from, you know, hospitals or medical clinics. It depends on the program, and you know, I think granted that now that HHS issues waivers as well for general, general psychiatrists and primary care, you know, it's possible for states, you know, Dr. Pinsky did the program, just create, you know, big medical clinics have offices, and you know, and they can create, and I've seen that, that they create these sites. And then it depends on if that particular clinic is in an MUA or a... Yes, and if it's in an MUA, and you know, states are, you know, willing to work with the clinic. One other quick thing, and then we'll be back, so talk to us if fellowships work under FLEX, like child psychiatry or addiction psychiatry, do they go under FLEX, or how do they apply? I think it's state, it's, it depends on what the particular state needs. And if it's a, if it's, again, everybody from general psychiatrists is taken out now from the states, so they would give it to specialists. But sometimes, right, if there's a greater need, and I know New York did this for a while, was a greater need in certain, you know, medical area, the medical practice, they'll give it to that particular practice. And, you know, not, let's say, you know, it all depends on the, on what's the need for this particular state. For FLEX, I believe it's, don't refer to my notes, 20% or 30% has to be in, teaching the treated, the population, 20, okay, so must treat underserved population, 20 to 40 percent of the population for FLEX. Okay, we'll take two more questions, and then, thank you very much. So I'll preface this by saying that I have been incredibly fortunate. I came in to do a fellowship. I was fortunate enough to be sponsored in H1B. I have been fortunate enough to be in the process of being sponsored on EB2 with NIW green card. So the way I think I envision the best way for APA, ECFMG, and IMGs to kind of work in this together is through advocacy, basically, which has been said throughout the talk. So I guess my question is, with the retrogression of almost all green card employment-based visa categories, what, in what way can the different organizations increase advocacy for at least something to be done? Because at the same time as this is happening, many states, I know at least in Minnesota, the Medical Board has been very vocal about the shortage of psychiatrists, and even the drainage of mental health specialists to other areas of medicine. So I think it's a curious situation whereby we need, we have an increasing need, and also kind of a stopgap after a certain point after training. So I can say a couple of things to that, and the first one probably won't be popular, and that's that because we are a sponsor for the J-1, which is a cultural exchange visa, and need to make sure that that partnership works with the Department of State, we cannot get involved in advocating, you know, beyond that, either for the waiver or progression to permanent resident, just because it's just too important that we maintain that relationship. I will tell you that a few months ago, I think February maybe, I was invited to the Senate Judiciary Subcommittee on Immigration, and went to Washington where there was a discussion about the need for health care workers in this country, and how can things, how can the laws, what can Congress do to facilitate pretty much, I think, what you're talking about, and there's good news, bad news. The good news was there was bipartisan support for that. The bad news was one party said they, even though they support, and it was talking about increasing the number of Conrad 30, or at least having them move from states, because clearly New York having 30 waivers, and in Montana, or somewhere less populated, has 30, doesn't make a lot of sense. There was agreement that that needed to be done. There was agreement that physicians should be able to progress from, into at least permanent residency, and citizenship faster than they are, but one party said they would never support that until the borders are secure, however one defines that, and so the whole discussion just ended there, but I think that there, and I'm speaking unofficially here, because I can't advocate for this, I think that there is a understanding and a desire for that, but it's unfortunately like everything else in Washington, in terms of how you're going to get people to agree. Yeah, I'll just add that, you know, our APA lead advocacy chief actually was one of the Conrad drafting people, and when all that came, so he's very well aware we keep talking about these issues, and you know, yes, it takes time, but again, we are persistent. Thank you. Last question. And if I just make a quick comment, as a practitioner, it's very frustrating, because we cannot provide clear answers, and especially for somebody in your situation, we get it, we know, but we are facing these roadblocks, so, you know, I tell everybody, if you're frustrated with the system, and if you are, you know, if you work for a big hospital, or for a medical system, they have them contact the Senator and Congress people, and tell them the need. There's certainly a recognized need for health care workers, I mean, we have shortage of nurses, we have shortage of doctors, yet the immigration system is in such state right now, that it hasn't changed. I'm not sure if it's going to change, I'm trying to be positive, but you know, just practice a lot of patience. At least, you know, the EP2 is not going to be retrogressed too much, so that's encouraging news, you will get the green card, but practice patience, and definitely, you know, have your voices, have your institution hear your voice. Yeah, and I would say, you know, do reach out to your Senator, just, I think there are links, all you got to do is put your name on it, and I'm happy to, you know, put some of those links from APA, there are a couple of bills that actively are looking at this, but they have been stalled, you know, initially for COVID reasons, and other reasons, and I think, but putting in a letter to your Senator, or your Congressman, I think those are always important to let your voice be heard. Hi, my name is Petrit, I'm a very busy child and adolescent psychiatrist in Naperville area, in Chicago, Chicago area, and you know, I'm from Albania originally, and I am very blessed to be in this country, and to have had the opportunity to practice medicine here, so when I learned in Athens that there is such eCFMG certification, and I said, wow, I was reborn, so thank you for providing that process for us to practice in US, and I'm the beneficiary of that, my, and it's very wonderful of APA to have such meetings, to reassure foreign grads that there is a path, and there is a, there is a process. My question is very practical for Mrs. Lugardician, Lucy Lugardician. I have a friend that she is in the first year in psychiatry residency, and she plans to stay in the United States. You said that a year prior to graduating, is there any, I mean, if she, if she applies two years prior, has to be a year prior, or like, you know, when they apply for these visas, or citizenship is within nine months, or prior to nine months? It depends on, I mean, usually, right, psychiatry is three years, or four year residency? Four years. Four years, okay. So by year three, you sort of know, you know, you're gonna get your offers of employment, so you have to start. She already has an offer. It's kind of difficult to say. If it's a Conrad State 30, depends on the state, where the physician is gonna go, what the requirements are, what the deadlines are. So, you know, it again, depends on that. If it's HHS, they are on a rolling basis, and the license, they have to meet certain requirements for, for the license, because you, they would need the license for the H-1B, and when the waiver gets filed, the application for the license has to be in place. So one year is to be sufficient? Usually one year. If they're doing hardship waivers, has to be longer now, but about a year. And again, she's, you know, your colleague probably is gonna work with an immigration attorney, follow the advice of the immigration attorney. I don't know the exact circumstances, so I can't really delve too much, just this general information. Thank you very much. Thank you, thank you so much. Truly appreciate our panelists for being here.

International Medical Graduates

U.S. healthcare system

psychiatry

Vishal Madan

William Pinsky

ECFMG

IMG applications

residency placements

visa challenges

J-1 visa

H-1B visa

green cards

healthcare shortages