Canadian Physicians
Intro. Canadian physicians enjoy several immigration and licensing advantages over other IMGs. Access to US employers, joint accreditation of Canadian and US medical schools, some licensing reciprocity, NAFTA and an exemption from the ‘unqualified physician’ exclusion ground give Canadian physicians better immigration options. This article explores such advantages, and other benefits not expressly for physicians but benefiting all Canadians including physicians.
Access to jobs is a primary advantage enjoyed by Canadian physicians. English-speaking and trained in equivalent methods and technologies to American physicians, Canadians are better poised to find work as physicians in the US than their IMG counterparts. US border state medical employers often recruit physicians in Canada. Many physician search firms operate jointly in Canada and the US. Credentials, professional societies and board certifications from Canada are widely recognized in the U.S. Canadians can enter the U.S. without visa processing to take those parts of the USMLE only administered in the U.S.- avoiding the visitor visa obstacle faced by IMGs. Hence, it is easier for a Canadian physician to find a job and easier for an American medical employer to consider a Canadian applicant.
After landing a US job, a Canadian physician faces the same hurdles as IMGs. These are: 1) a license and 2) a work visa. For Canadian physicians, these two hurdles, particularly the license hurdle which is often a preliminary requirement to the visa, are far lower than for their IMG counterparts.
License Requirements. For all foreign nationals, the license step is more difficult and time-consuming than the visa step. For IMGs, securing a license usually means completing a 3-year residency training program in the US, successfully passing the three Steps of USMLE, attaining ECFMG certification and having their medical school credentials verified by FCVS (or like organization) or the state medical board.
For most IMGs, these preliminary steps to state medical licensure can take 4 or 5 years. Most if not all IMGs are already fully credentialed practicing doctors in their home countries. While Canadian physicians are also usually fully trained professionals in their home countries, they are unique compared to other foreign physicians in that they can usually avoid repeating a residency training program in the US, do not need to take USMLE or be ECFMG certified to gain a license, and do not need FCVS or other educational credentialing.
Thus, a Canadian physician is several years ‘ahead’ of another foreign physician in starting a clinical career in the US.
Visa requirements. In tandem with immigration rules not requiring USMLE for physicians able to qualify for H-1B international renown, L-1, O-1, E-2 business investor visas or TN research and teaching only classifications, the license benefit allows Canadian physicians access to US medical workplaces without USMLE or repeating residency training at all.
In the immigrant visa context, this license benefit is even more meaningful. Although an IMG must have USMLE (which in turn requires US residency training) in order to immigrate in the EB-2 or EB-3 categories, a Canadian physician does not need USMLE at all to immigrate as EB-2 or EB-3 or indeed any other IV category, such as IR-1. Of course to practice clinical medicine, a Canadian physician must have a state medical license.
Summary conclusion. The point is -- a Canadian physician may pursue a green card and a license concurrently and based on Canadian education and training, expending perhaps 18 months total to reach the goal of entering the US as a permanent resident with an unrestricted state license. By contrast, an IMG is subject to circular requirements: USMLE -- which for most jurisdictions requires completing a portion of an accredited residency training program prior to sitting Step 3 -- which in turn requires ECFMG certification. An IMG can easily spend 8 to 10 years to attain the goal of entering the US as a permanent resident with an unrestricted medical license. [8 to 10 years being the sum of 4 to 5 years to complete USMLE, ECFMG certification, find and complete and training program, and 4 to 5 years also to serve out the J waiver 3 year shortage area service obligation, then adjust status to LPR. Of course for Indian or Chinese physicians seeking to immigrate in the EB-2 or EB-3 categories, this 8 to 10 year time line is longer by 3 or more years.
Because the clinical medical licensing process for foreign physicians is the crux of the visa challenge, this article starts with a discussion of Canadian physician advantages in the licensing process, and then surveys NIV and IV advantages for Canadian physicians that together give Canadian doctors relatively streamlined pathways to practice clinical medicine in the U.S.
Disclaimers. To forebear from detailed definitions of terms or a survey of 50 states’ different license requirements, general terms and general license requirements are stated here. To focus on present rules, the also interesting history purpose and evolution of current requirements is not discussed. Citations to reference materials containing state by state specifics from FSMB, USMLE and ECFMG are included in endnotes. Tables of abbreviations and web links to resources are also appended.
1. U.S. State Medical licenses
Medical Graduates
Because Canadian and American medical schools programs and residency training programs are jointly accredited by the same organizations, LMCE and ACGME respectively, state medical licensing boards put Canadian and American medical graduate applicants on roughly similar footing: an initial license is generally available to those with an MD, one year of accredited post graduate training, and passing USMLE scores. Physicians complete a 3 year or longer training program to gain privileges, jobs, and board certification, but can be licensed to practice medicine after just one year of training in many US jurisdictions. Canadian and American medical graduates who have passed USMLE then, may enjoy clinical licenses just one year into their residency training. This initial license permits moonlighting in ERs, for example, outside of the residency training hospital.
Physicians
State medical boards also put Canadian physicians on roughly similar footing as American physicians licensed in other U.S. states: requiring MD, Canadian license, LMCC passing scores (and some professional experience, ref. NYS). Thus a Canadian licensed and practicing physician, like a physician licensed in another US state, can earn a medical license without re-sitting for a licensing exam. In other words, most American states ‘endorse’ a Canadian medical license, obviating the need to sit for USMLE.
IMGs
However, state medical licensing boards have much stricter requirements for IMGs. State medical boards IMG license requirements are somewhat uniform and generally include :
1) USMLE Steps 1, 2 cs 2ck, Step 3*
2) ECFMG certification (used for English language assessment)
3) 2-3 years postgraduate training in an ACGME accredited program (meaning US or Canada)**
4) verification of foreign educational credentials, in many instances through FCVS or like service.
*some states such as Minnesota still accept LMCC exam, and USMLE itself accepts some USMLE precursor exams such as NBME and FLEX in lieu of all but Step 3 of USMLE. (No. The USMLE program stopped accepting precursor exams for the purposes of Step 3 eligibility on January 1, 2000.
2. State medical licenses for Canadian physicians
Under certain circumstances, a Canadian physician may bypass all 4 of the above requirements for IMG licensing.
USMLE
Since 1995, USMLE has been the only medical licensing exam administered in the U.S. Prior exams such as FLEX, NBME and FMGEMs, were previously accepted for licensure and satisfaction of visas requirements for H-1B physicians or EB-2, EB-3 green cards (i.e. unqualified physician exclusion ground). In the early nineties, combining parts of different exams was acceptable for state medical licensure and permanent visas. Today, USMLE is unavoidable for all but certain Canadian physicians and a few foreign physicians who earn licenses through discretionary approval of a state medical board.
For example to gain a medical license in New York, a state recently home to 50% of all IMGs in training positions, a Canadian physician with professional experience can avoid USMLE if the physician is licensed in Canada with 2 years of professional experience and passing LMCC (Canadian medical exam) scores.
Also in NYS for example, a foreign national educated at an accredited Canadian medical school with one year of postgraduate training at an accredited training program, and USMLE or comparable US licensing exam, may receive an initial US state medical license. By contrast, other IMGs require 2 to 3 years of post graduate training in the US before being US state license eligible. Hence, the Canadian medical graduate gets credit for the one year of Canadian training whereas the non-Canadian IMG gets no credit for the foreign training and must repeat de novo the residency training and take USMLE.
Taking USMLE in the first place is much simpler for a Canadian physician. Steps 1 and 2 clinical knowledge may be taken during training, and may be taken outside of the United States. Thus all foreign physicians have equal access to sit for these parts of the exam. Step 2 Clinical Skills may only be taken in the U.S. Step 3 may only be taken in the US and in most states requires prior completion of at least one year of accredited training (in US or Canada). Hence, IMG must first secure a B visa to visit the United States to sit for Step 2cs. B visa refusal rates top 50% in many parts of the world. For Canadians however, entry to the U.S. to visit or take the Step 2 cs is unimpeded by visa practice. A prerequisite for sitting USMLE step 3 is ECFMG certification. Many jurisdictions also require current enrollment in a US or Canadian residency training program or completion of a minimum number of months. Thus, IMGs must be fully credentialed and training in the US before completing the final step of the licensing exam. A Canadian medical graduate however is exempt from both the ECFMG and the US residency prerequisites to step 3 applicable to IMGs, by virtue of the certification of the Canadian medical schools where English is the language of instruction and the certification of Canadian training programs as equivalent to US training programs.
ECFMG
ECFMG is a gatekeeper to US residency training programs. ECFMG administers clinical and language exams to IMGs, evaluates their educational credentials and certifies them ready for US training opportunities. In order to attain ECFMG certification, an IMG needs to pass USMLE Steps 1 and 2 and pass the educational credentialing process. Thus, even though the state licensing boards only look to ECFMG to certify English language abilities, as the state licensing boards separately evaluate foreign educational credentials, to show ECFMG certification, an IMG must pass the USMLE steps 1 and 2. Canadian physicians by contrast are free of these circular requirements. They are exempt from the ECFMG certification requirement as their English language abilities are implied through the LCME accreditation of their medical school.
“Fifth pathway” used to be a means by which IMGs could bypass ECFMG certification by completing one additional year of medical school in the US. At the end of calendar 2009, the American Medical Association will no longer offer this one year program and fifth pathway is effectively extinct .
ACGME training program
An IMG encounters the ACGME training program requirement in 2 ways. First, most state license boards require 2 to 3 years of accredited training for licensure, essentially granting no credit for foreign postgraduate medical training programs. Some states such as Maine, Illinois, Michigan, Nevada, New Hampshire, New Mexico, South Dakota, Utah, Washington, West Virginia and Wisconsin do not require more post graduate training of IMGs than American physicians. However, even in these states, an IMG encounters the ACGME training program requirement when registering for step 3 of USMLE, as most jurisdictions require at least one year of accredited training prior to taking the exam. Taking Step 3 of USMLE requires at least one year in an ACGME accredited training program . As USMLE is necessary for a state medical license, for an H-1B visa, or for a green card in the EB-2 and EB-3 categories, one year of accredited training is implicitly necessitated by the license and visa process for IMGs.
Thus, an IMG will compete in a highly competitive field in a foreign country in order to gain a residency position that will bring low pay, long hours and difficult work. After three years of training, an IMG may satisfy the post graduate training requirements of any American state. In sum, the accredited training program requirement is both an overt state license requirement and an implied requirement of USMLE, which is needed to attain a license, a green card and an H-1B visa.
By contrast, a licensed and practicing Canadian physician with two years of professional experience in Canada is already license eligible in any American state.
FCVS
State medical boards rely on ECFMG certification for English language assessment, however they separately evaluate a candidate’s educational background. Many states ‘farm out’ this credentialing process to a service like FCVS. 13 states require FCVS and the balance of the states suggest it. A Canadian physician’s credentials, meaning an MD from an accredited medical school program and training at an accredited training program do not require outside evaluation. Canadian physicians are not considered IMGs for state license purposes. Avoiding the FCVS process can save several months and several hundred dollars in the licensing process for Canadian physicians.
In NYS, a foreign physician who is not yet an LPR must have a contract for clinical work in a shortage area in order to get a state medical license (known as a Limited License in that it is geographically limited to a shortage area). This additional restriction equally affects Canadian physicians and IMGs seeking NIV status to work in New York.
In conclusion, avoiding taking USMLE is the most useful advantage realized by Canadian physicians seeking to work in the US, as avoiding USMLE means, in most states, avoiding additional training and avoiding ECFMG and FCVS certifications.
Visa Options
As a legal matter, Canadian physicians compared to IMGs only enjoy a few narrow NIV advantages, such as TN and E-2. As a practical matter however, many NIV options are more workable for Canadian physicians than their IMG counterparts. Together with the powerful licensing advantages discussed above, a Canadian physician’s pathway to the US is much simpler than that of an IMG.
H-1B international renown. The H-1B international renown category is still a viable part of the NIV structure even after the introduction of the somewhat similar O-1 category in 1990. H-1B international renown classification permits a physician to qualify for H-1B without USMLE if it is shown that she/he “is of national or international renown in the field of medicine.” 8 C.F. R. 214.2(h)(4)(viii)(2)(C). No regulatory criteria define “national …renown.” By contrast the O-1 criteria require “sustained national or international acclaim and recognition” and enumerate specific types of evidence needed.
Canadian physicians may more readily show “national or international renown” than their IMG counterparts because the linkage between US and Canadian medical schools, training programs, Board associations, professional journals and trade organizations allows a Canadian doctor to present familiar, English-language documents that are by definition ‘international’ credentials. Moreover, a Canadian physician exempt from the USMLE requirement is by definition a practicing physician in Canada who is more likely to have professional attainments. Hence, a Canadian physician who gains an American state medical license may get H-1B status in the international renown category without USMLE, through the international renown avenue, which is a lower hurdle than the O-1 and easier for a Canadian to satisfy. Canadian physician without an American state license or USMLE may enter in H-1B if there is no direct patient care (such as an administrative MD job).
O-1 Extraordinary Ability
By the same factor of commonality of professional credentials, an O-1 is more workable for a Canadian physician than for an IMG. An IMG making an O petition usually relies on evidence acquired in the U.S. while in a training program. Thus, residency awards, publications written while in training, memberships attained while in training are typically submitted for IMG O petitions. By contrast, a Canadian physician may rely on evidence from a professional medical practice in Canada to show O eligibility. Thus a Canadian physician may apply for O status from Canada, before entering the US, while most IMGs only seek O after being present (usually in a training program) in the US for several years. Credentials such as Royal College of Physicians and Surgeons, American Board certifications (also available to Canadian doctors) and diplomas and training certificates from recognizable and accredited programs are familiar in the U.S. And, it is easier for a referee’s support letter for an O petition to speak to the high caliber of the educational or training attainments when those programs are accredited by LMCE and ACGME.
E-2 and L-1
While it is almost inconceivable that an IMG be a treaty investor or multinational manager of a U.S. medical business, a Canadian physician could own and operate a US-based medical business that allows E-2 or L-1 visa status. A cross-border business is conceivable given the harmony of US-Canadian medical regulatory practices. Patients from Canada also commonly come to the US to private pay for procedures for which they might wait a long time under the Canadian government sponsored health care system. Accordingly, a Canadian physician operating a cross border clinical business benefits from physical proximity, a ready patient base and commonality of business and professional medical practices in the US and Canada. For a Canadian physician who has a state license, E-2 or L-1 visa status is conceivable for a clinical medical practice also. For example, an OB-GYN practicing in Ottawa may also own a medical services office in NYS through which business she attains E-2 or L-1 status. Cross-border medical practices of this type are not uncommon along the northern border.
A non clinical physician-owner of a medical supply, medical consulting or pharmaceutical business could also qualify for E-2 or L-1 status to direct the US business without needing a state medical license. Thus, for example a Canadian physician could work in a medical business in the US without needing a license at all. Note however, that for the US business to be a professional corporation, a state professional license is required, and in New York at least, a state license is only available to a non permanent resident who practices medicine in a shortage area. Thus an E-2 or L-1 status for a non-clinical medical business is not possible if the business structure is a p.c. in a state where a clinical license requires the practice of medicine.
TN
The generally advantageous TN category benefits few Canadian physicians as it is limited to ‘teaching or research’ positions only and has been adjudicated to disallow positions including more than ‘incidental patient care.’ Thus, TN’s are not useful for residency training positions. See Bednarz letter. Although the new Visa Screen requirements for allied medical professionals are not required for TN Physicians, there are still limited opportunities to use the TN category for physicians as there are limited jobs for physicians that entail teaching and research only. Most academic appointments for physicians are dual positions at affiliated hospitals and universities and thus include more than incidental patient care, making inappropriate use of the TN vehicle.
Immigrant Visa options
IMG EB-2 and EB-3 --the Embedded USMLE requirement
The all important ‘unqualified physician’ exclusion ground at 212–a-5-B subjects IMGs immigrating in the EB-2 or EB-3 categories to USMLE independent of license or job requirements. IV rules for IMGs thus have an ‘embedded’ exam requirement. E.g., a Nigerian doctor immigrating pursuant to a Special Handling EB-2 immigrant visa to teach midwifery at a local university needs USMLE (which as above usually requires repeating a residency program) even though the position doesn’t require a license or a licensing exam. INA 212-a-5-B thus creates a DOUBLE USMLE requirement for IMGs (once for a license and once for a visa) and imposes an exam requirement even where the job itself does not require it. Medical professional jobs such as hospital administrator, business owner or pharmaceutical rep are in the EB-2 and EB-3 category and thus require an IMG to show she/he is not an ‘unqualified physician’ in the only way possible for a non-Canadian physician – passing USMLE. See Weinig letter and 1990 act history that limits 212–a-5-B to EB-2 and EB-3 but applies equally to non-clinical positions.
INA 212-a-5-B essentially says that except for a graduate of an LCME accredited medical school, a physician immigrating in EB-2 or EB-3 must show passing USMLE and English language certification from ECFMG certification.
The unqualified physician exclusion ground does not apply to DV, IR-1, investor, EB-1, family based or asylee immigrants. Hence an IMG could immigrate in one of these categories and work in a non-clinical medicine profession in the U.S. For a Canadian physician, immigrating in one of these categories and then following the relatively simple pathways to state licensure permits clinical practice without USMLE and other requirements.
EB-1 and discretionary licensing
Physicians of any country’s origin may immigrate in the EB-1 category without reference to the unqualified physician exclusion ground. However, attaining a state medical license is still a set back for IMGs unless the physician is so highly credentialed as to qualify for a state license through a discretionary credentialing process. In NYS for example, this discretionary process is called “Endorsement.” Although seldom used, endorsement is still a discretionary pathway to licensure for 10 or so physicians per year whereby the state medical board internally evaluates and waives education and testing requirements for certain highly credentialed applicants, who are already PRs. Thus in NY, the Board of Regents may approve a license by Endorsement for a highly credentialed French surgeon who pioneered a technique for heart arrhythmia that involves slicing one of the ventricles, but only after this surgeon has immigrated. The surgeon must immigrate in the EB-1 category to be free of the ‘unqualified physician’ exclusion and then can attain a license without USMLE. For a few rarely skilled Canadian and IMG physicians then, immigrating in an EB-1 category or through family sponsorship, and getting a license through a discretionary pathway may allow equally to both kinds of physician avoidance of USMLE and repeating residency. Query however the likelihood of securing a job offer needed for EB-1 qualification without having state license eligibility established. Thus, while legally possible to get LPR status and then a discretionary medical license it is not practically possible that a US employer will contract with a highly skilled foreign physician who does not possess a license.
INA 289
Canadians do enjoy one unique IV benefit that could conceivably be an option for a Canadian physician. INA 289 is a seldom used statutory benefit for American Indians born in Canada that accords LPR status upon POE application for admission to those who can show 50% American Indian blood and Canadian nationality. The most expedient and not entirely impossible licensing and immigration pathway for a Canadian physician is thus the presentation of qualifying tribal status at the POE, followed by application for unrestricted state medical license based on ‘reciprocity’ with the Canadian license.
Worldwide chargeability, Visa exemption, US-VISIT benefits, and commuter alien status:
Canadian nationals in general benefit from facilitated US immigration process requirements. These benefits allow Canadian physicians quicker and more flexible access to US employment.
Worldwide chargeability of Canadian physician immigrant visas means quicker processing for IVs. This allows a northern border based US employer for example, who recruits a Canadian physician 18 months or so in advance, as is not uncommon for medical employers, to file and attain a PERM based EB-2 IV before the job start date. The recruited Canadian physician can then enter the US in IV status and attain an unrestricted license before starting work. By contrast, filing PERMs before an IMG physician has completed training is difficult because truly that applicant is neither licensed nor license eligible, nor qualified for the job if the job requires a certain number of years of training, at the time of filing of a PERM. However, Canadian physicians who are not subject to a repeat residency requirement are truly ‘license eligible’ and possess the necessary amount of training at the time of filing of a pre-job PERM. Hence the IV can be filed earlier and approved faster for a Canadian physician as compared with an IMG.
Because of the above IV EB-2 PERM advantages, NIW applications are not attractive options for Canadian physicians. NIW candidates are usually quota delayed Indian or Chinese physicians who also have a J waivered 3 year service obligation. For such a client, a 5 year work obligation does not prolong the attainment of LPR status. For Canadian physicians who can attain IV status more quickly, there is no advantage in considering an NIW process.
NIV visa exemption hastens processing and travel for all Canadians, including physicians, and particularly benefits 212-e subject physicians who have not attained waivers or satisfied their J home residency obligation. The Canadian visa exemption is especially advantageous in the present climate where lengthy delays at consular posts attend NIV interview booking and processing. A Canadian physician with an approved E, H, L, O or TN may start work months in advance of an IMG counterpart who must travel abroad and be issued a visa at a US consular post. Because the various background check procedures are triggered by requests for visa issuance, a visa exempt Canadian avoids the time and hassle involved in travel, consular interviews and background checks.
The visa exemption as applied to J visa holding Canadian physicians essentially suspends the impact of 212-e until a Canadian seeks LPR status. INA 212-e blocks change of status or visa issuance in the H, L or LPR categories for J visa’d foreign physicians including IMGs and those Canadian nationals who train in the US through ECFMG sponsorship unless a waiver or fulfillment of 212-e is shown. Because a Canadian physician can enter the US in NIV status without either COS or visa issuance at a consulate – by simply crossing the border carrying an I-797 approval notice, 212-e is an ineffective block for NIV admission until LPR application is sought. Hence, a Canadian physician approved for an H or L visa may reenter the US through a POE without a waiver or fulfillment as POE admission of Canadians requires neither a visa nor change of status pre-approval from CIS. See 1994 Bednarz letter clarifying J to O without waiver process.
Similarly, because a Canadian carries no visa, no annotations of prior 212-e obligations are revealed by a Canadian physician’s immigration documents. Thus, a non-Canadian IMGs’ new O visa is often annotated to show “remains subject to 212 –e” whereas without a new visa issued at all, Canadian O-1’s who were previously J’s may sometimes attain a change of status form O to H, as CIS does not reference the nonimmigrant history and form I-129 and H supplement do not inquire about possible 212-e application.
Under US-VISIT, Canadian physicians and other Canadians enjoy document simplification. The passport requirement may be satisfied by enhanced state or provincial license documents issued in the US or Canada. This means that a Canadian entering the US to work may present only an enhanced license and an I-94 card, speeding processing and limiting inspection inquiry. The full list of documents accepted from Canadian citizens includes: a passport issued by the Government of Canada, a valid trusted traveler program card (FAST, NEXUS, or SENTRI), or an Enhanced Drivers License. U.S. and Canadian children under the age of 16 will be able to present a
birth certificate or other proof of citizenship.
Commuter alien status allows Canadian physicians who have immigrated to the US for work to disregard the ‘abandonment’ rules requiring PRs to reside permanently in the U.S. By exchanging her green card for a commuter alien card at a POE, a Canadian physician for example may live in Canada and commute to work in the U.S. while still enjoying the job flexibility and licensing privileges associated with PR status.
Hardships in US immigration and licensing for Canadian physicians
Naturally, some detriments attend the general benefit of being a Canadian physician as opposed to an IMG. These include the near impossibility of proving ‘hardship’ for purposes of a 212-e waiver for a US trained Canadian medical graduate. Attaining J status at all for a Canadian national who graduated from medical school in the US is difficult as Canada will not issue the home country letter needed for ECFMG sponsorship to a doctor who has never trained or practiced in Canada. Thus a Canadian national who attends medical school in the US on an F visa is usually limited to an H visa for residency in the US, which H visa status is of course a problem where the anticipated course of training lasts 5 or more years.
Conclusion
Medicine is one example of internationalization of professional business between the US and Canada. Canadian physicians unlike their IMG counterparts possess readier access to American workplaces via facilitated license and visa rules for Canadians.