Residency in America

In order to enroll in residency in the United States, whether AOA or ACGME, you will need a new visa. There are two possible visas for this:

 

H1B Visa
J1 Visa

 

Here is the bottom line: If you are not a dual US-Canadian citizen (i.e. Canadian citizen only), you will need either an H1B or J1 visa to pursue residency in the US. Not all ACGME programs will issue a visa, so it is important to confirm the policy of each program you are considering. Do not apply to hospitals that don’t sponsor visas.

 

Usually, this information can be found on the residency program website. Sometimes, you may have to contact residency programs directly to confirm whether they sponsor visas. Many programs list their residents on their websites with details about their hometown or undergraduate university. This is one way to infer whether the program is Canadian-friendly. Unfortunately, residency databases such as FREIDA and the AAMC Residency Explorer may not have the most up-to-date information.

This process can be logistically challenging and involves a word salad of terminology. Read more below to understand both visas and what they entail. 

H1B Visa

 

The H1B visa is known as a "temporary worker visa" for individuals working in a "specialty occupation", that is, an occupation requiring a Bachelor's degree or higher. It also allows for "dual intent", meaning you can return to your country of citizenship after your work term has been completed or pursue immigration (i.e. Permanent Resident (PR) status/"Green Card") to the United States. 

This visa is the best option as a Canadian citizen in a US residency as it allows the resident to stay in the US for 6 years before needing to be renewed and opens up the possibility of obtaining PR status. The requirements for an H1B visa include graduation from medical school and passing COMLEX Level 1, 2, AND 3 or USMLE Steps 1, 2, AND 3.

Applying to Residency

As most non-citizen graduates from US medical schools complete Level 3 or Step 3 during their PGY1 year, they will need a designation to bridge that year before receiving their H1B. This is usually accomplished with an OPT (Optional Practical Training) year, which is an extension of the F-1 visa that was used to attend your US medical school. Your school should help you with this. It gives you an entire year to complete COMLEX Level 3 or USMLE Step 3, as well as apply for, and receive your H1B visa. The H1B visa would then go into effect at the start of your PGY2 year.

 

This OPT year is key because otherwise, you would need to graduate med school in May, submit an application to take COMLEX Level 3 or USMLE Step 3 (requires med school graduation as a prerequisite), take and pass Level 3 or Step 3 and receive said results, and apply for and receive your H1B visa, all before July 1 in order to start a US internship/residency on time. This is pretty much impossible even for the most determined students. Visa processing delays are frequent and out of your hands. If you use the OPT year, then the H1B visa becomes a much more viable strategy.

Unfortunately, many US residency programs do not sponsor H1B visas as it is expensive for programs (no, you can't pay for them by law) and requires significantly more paperwork from them than a J1 visa. Note that as the competitiveness of a specialty or its location increases, the likelihood of a program offering H1B visas decreases, since they will fill their spots regardless of citizenship. Conversely, if you are applying for something like Internal Medicine, Family Medicine, Pediatrics, Psychiatry, etc, all of which are relatively less competitive and often fill their vacant spots with IMGs, you are much more likely to receive H1B sponsorship. Intermediate difficulty specialties will be somewhere in the middle in their stance on offering H1B visas.

 

During and After Residency

The H1B visa allows you to be employed in the US, allows you to moonlight during residency, and also puts you on the pathway to obtaining PR status, which lets you live and work permanently in the US. After completion of residency on a H1B visa, you must either leave the country or find a new job in the US that will sponsor you for another H1B visa. While on an H1B, you can apply for PR status. The wait times for obtaining PR status are based on your country of birth (not the country of citizenship), which can be anywhere from 2-12 years depending on the country of birth. During the wait, you can continue to work in the US as long as you have an employer sponsor a H1B visa for you.

The other option is a J1 visa. These visas are sponsored by almost every residency program. To get a J1 visa, you have to get a statement of need from Health Canada. Basically, every year Health Canada releases a list of medical specialties Canada needs physicians in. Each specialty will have a certain number of Statements of Need that Health Canada will issue to Canadians training in the US.

J1 Visa

 

The J1 visa is an "exchange visitor" visa, which means it only allows you to stay in the US for the duration of your post-graduate training. Once you finish your training, you must return to your home country for 2 years (Canada or other) before you can return to work in the US on a different visa (such as an H1B visa).

Applying to Residency

The major advantage of the J1 visa is that there are fewer paperwork requirements for the residency program, thus many more programs offer the J1 versus the H1B visa. The J1 visa requires Health Canada to issue a Statement of Need (SON). You also need to make use of a US organization called the ECFMG, which will act as your J1 visa sponsor. The ECFMG paperwork is relatively straightforward.

 

It is important to be familiar with the process and apply for a SON on time. The earliest you can apply is the day NRMP match results are released. In the event you match into a residency and can't secure a SON, you will not be able to get a J1 visa and start residency. You do not need to apply for a SON every year of residency. You would apply before you start and it remains valid over your entire length of training.

Starting 2016, all specialties will have limited endorsement SONs. This means that Canada will only issue a certain number of SON on a first-come-first-serve basis. Family Medicine continues to have the largest number of SONs. COMSA recommends that 3rd and 4th-year medical students check the updated limits every year. They are usually released in August. More information about timelines and limits can be found on the Health Canada website.

 

The Health Canada administrator for the Statement of Need program can be contacted at:

 

Ph: 613-952-1912
Fax: 613-948-8081
j1visa@hc-sc.gc.ca 

After Residency

Once you complete residency, you must return to your home country for 2 years. If you choose a US residency that is recognized as equivalent in Canada, you can take the Canadian Royal College of Physicians and Surgeons exams. If you pass them, you can come back to work in Canada with a few steps. Those are detailed here.

Alternatively, you can also complete a fellowship in Canada while simultaneously fulfilling the 2 year home residency requirement. After fulfilling that requirement, you may look for an employer in the US willing to sponsor you for an H1B. Then, you can reenter the US to work.

You can obtain a waiver for the return to home requirement. This is through working in a federally or state-designated underserved area or at a government institution (such as the VA hospital) for 3 years.

 

Once you obtain a J1 visa, you cannot convert over to an H1B visa without either fulfilling the home residency requirement or obtaining a waiver. Marrying a US citizen will not get you past the requirement.

Final Note

This page is intended to cover the basics of visas and residency and is not comprehensive nor can it be regarded as immigration advice. Please consult additional resources or an immigration attorney regarding your individual circumstance if you have further questions.