Several changes have been made recently to the Exchange Visitor Program (EVP) as it applies to physicians beginning and graduating from residency programs. The EVP is the program administered by the U.S. Department of State that allows a foreign national to enter the United States on a J-1 training visa to participate in an educational program. In the case of foreign nationals who seek to undergo medical training or conduct medical research, the Educational Commission for Foreign Medical Graduates (ECFMG) administers the program and acts as the J-1 visa sponsor for the physician.

Changes Affecting Physicians Who Are Beginning a Training Program
In February 2002, the ECFMG issued a notice indicating that the Department of State had informed the organization that sponsorship of foreign nationals for training in programs not accredited by the Accreditation Council for Graduate Medical Education (ACGME) would be permitted only through June 30, 2003, unless a recommendation for an acceptable modification of this policy was forwarded to the Department of State. This program limitation had the potential to significantly hamper the recruitment efforts of a number of training programs (referred to by the parties involved as "non-standard programs") in major teaching hospitals in New York and across the country. For this reason, GNYHA had been in continual communication with the ECFMG expressing its members' concern with potential new restrictions on the program.

Following extended discussions with the academic medicine community and the Department of State, the ECFMG recently forwarded an acceptable recommendation to the Department of State. The ECFMG will continue to sponsor J-1 physicians for participation in training programs if any one (or more) of the following conditions applies:

1. The program is accredited by the ACGME.
2. The appropriate specialty board of the American Board of Medical Specialties (ABMS) offers a certificate in the specialty.
3. The appropriate specialty board of ABMS recognizes the program, as evidenced by a letter of support, and additional requirements are met.

For this third category of program, the training program's sponsoring institution must be in good standing with the ACGME and must submit additional required documentation, including a detailed program description and a statement from the applicant's home country, indicating a need for the specific specialty training included in the program. To date, a majority of the 24 ABMS boards, including the American Boards of Internal Medicine, Pediatrics, OB/GYN, and Surgery, have indicated either their general support for certain areas of specialty training or their willingness to review particular training programs and provide letters of support on behalf of applicant physicians. The ECFMG anticipates receiving additional responses, and will be posting information regarding the process for each Board on its Web site, www.ecfmg.org.

Changes Affecting Physicians Who Are Seeking a Waiver
One key feature of the Exchange Visitor Program and the J-1 visa is that foreign nationals who enter the United States on this visa are subject to a two-year home residence requirement following the expiration of the visa. In the case of residency trainees, following completion of a training program, physicians are required to return to their home country if they do not receive ECFMG sponsorship for additional training (for example, subspecialty) or receive a waiver of this return-home requirement. The total period of sponsorship by the ECFMG is generally limited to seven years.

The waiver of the return-home requirement is accomplished by means of a request made to the Department of State by an interested government agency (IGA). In the past, numerous Federal agencies, including the U.S. Department of Housing and Urban Development (HUD), have acted as IGAs and have made requests for these waivers as a means of ensuring adequate health care services in underserved areas. These waivers result in the physician being granted an H-1B temporary worker visa under the condition that the physician work for a minimum of three years in a federally designated health professional shortage area (HPSA), medically underserved area (MUA), or in a Veterans Administration facility. In 1996, HUD stopped participating in the program as an IGA for J-1 physicians seeking to remain in this country. The U.S Department of Agriculture also recently stopped submitting requests for waivers.

In December 2002, HHS published an interim final rule, with opportunity for comment, indicating that effective immediately, the agency will formally act as an IGA and request waivers for physicians on J-1 visas to receive an H-1B visa so long as the physician agrees to provide primary care services in a designated primary care HPSA or MUA, and for psychiatrists to provide care in a mental health HPSA.

Although there is increasing evidence that various specialty-trained physicians are needed, Federal agencies are currently prohibited from acting as IGAs on behalf of physicians to provide other than primary care or psychiatric services. Greater New York Hospital Association commented on the final rule, expressing its members' support for the HHS decision to formally act as an IGA and requesting that the agency seek a change in the prohibition on also granting waivers for physicians delivering non-primary care and non-mental health services.

In November 2002, President George W. Bush signed into law an expansion of the program allowing any State Department of Health to act as an IGA for the purpose of sponsoring waivers for J-1 physicians who are seeking to remain in this country. The program, which had been referred to as the "Conrad 20 Waiver" program after Senator Kent Conrad, the original sponsor of the bill in 1994, now permits states to increase their annual waiver applications from 20 to 30. As with the HHS program, the physician who are seeking the waiver from the return-home requirement must agree to work full-time in an HPSA or MUA for at least three years on an H-1B temporary worker visa. Unlike the Federal agencies acting as IGAs, the states may sponsor non-primary care physicians for these waivers. In New York, priority has been given to physicians who are providing primary care services, although the State does consider other applications as well.