Good morning, everyone. Welcome to the final day. Hopefully, we still have enough energy to get through it here. There is a lot of programming after this session, so I encourage you to attend some excellent sessions before you depart. And then today, we have our session on practical tips for foreign medical students, medical practitioners, scientists, et cetera, working in the U.S. or planning on coming to the U.S. So Ricardo has some slides that he'll present, but it's going to be really informal. We're here to help you and give us our slightly biased insight. So we'll start. My name is Eric Nelson. We're currently working at the University of Illinois in Champaign-Urbana. I'm originally from Canada, and I moved to the U.S. to do my postdoc. So I have some experience in navigating the immigration and visa system, although Canada is a little bit different than other countries in the world. So I'm happy to provide my insight. And then joining me to your right would be Ricardo Carrera, who's an associate professor and the program director for Endocrinology, Diabetes and Metabolism Fellowship and the director of Diversity in Graduate Medical Education at the University of Arizona College of Medicine. And he's going to share some slides and his expertise coming from more of a clinical standpoint. And then in the middle here is Dr. Antonio Larario, who's an MD-PhD and is associate research scientist at the University of Michigan Medical School in the Department of Internal Medicine at Ann Arbor. And then on the schedule is Claudio Ramirez Bustamante, also an MD and endocrinologist and fellow physician at Baylor College of Medicine. And so hopefully she shows up and can impart her words of wisdom as well. But to start, maybe you want to load your slides. And like I say, very small crowd, so we can be very informal. Just interrupt us if you've got questions or if something sparks in your memory and you want more clarification. We're here for you. Yeah. Thank you so much for the introduction. So first of all, thank you so much for attending this session. I think that for several years endocrine society has realized that international medical graduates and international scientists are important for the society. And they usually put a session like this to let all of you know a lot about the struggles that we had, that probably you are having. And this is how we help in international medical graduate system is peer-to-peer support, mentoring support, because if you are not an international graduate, you don't understand what we suffer or what we go through. So that's important. And something that I just want to clarify, because probably I didn't update that in my bio, I transitioned from the University of Arizona to the Cleveland Clinic. Now I'm the program director there at the Cleveland Clinic. But we have a representation from the University of Arizona. So Dr. Karine Vinales that is here, she is our chief at the VA of the endocrine division. So she can help us guide. And I will tell you a little bit of experience. So I met Karine in a session like this seven years ago, six years ago. And I never, I was not at the University of Arizona. I was in another institution. And she came and then after that she approached me and said, hey, you know, how can I get involved in more things? And then we got involved in a young physician committee. And then I went to work at the University of Arizona and she became my friend. So just in a meeting like this that never expected, now she's one of my best friends. So you see the importance of sometimes we bonded as an international medical graduate. And what I want to talk here today is basically a little bit of my experience, probably not similar to you, probably similar to you. And then the reaching part of all of this is just to ask, to understand your question and see how we can help or how we can guide you to another person that can help you. I have my disclosure is that I am the past chair, Intermediate Chair for the American Medical Association for the International Medical Graduate Section. And I have been involved in international medical graduates since many years ago in many, many organizations. So the first thing is when you're looking for a job, it's difficult and different from the standpoint of the U.S. medical graduates. You understand there are many pathways. There's academia pathway, there is an industry pathway, there's private practice, some hospital base, a community base, and the government. For international medical graduate that are in visas, not every international medical are in visas, so I'm a U.S. citizen or permanent resident. But for the international medical graduate that are in visa, usually after finishing your fellowship is a clinical job if you are a clinician, if you are in the MD pathway. So it will be more a type of clinical job and it will be in rural area. The second thing important is that we represent 80% of all the practicing physicians in rural America. And we need this to make clear to all the federal government and all the institutions that do not appreciate international medical graduates. We came to this country in the 60s because there was not enough physicians. And we have been discriminated since that time. They bring us here for a purpose, to help the country. We have been doing that. We have been practicing 90% of our time, 80% of our IMGs are in rural America. And these are the people that stay in rural America and these are the people that continue caring for that. And we represent 25% of all the physician practicing in the U.S. One-fourth of the physician practicing in the U.S. are international medical graduates. And this is things that we need to get together because I think that as a community we are not together and tell others and tell the people. Because sometimes you see during the prior presidential period that we have so many issues and we have to tell people that we are taking care of them in rural America. That is the one underserved area that is very needed. But in all this pathway that you can have as an international medical graduate, mentorship is key. Because if you have some person that guides you, then you can achieve any of this. But at the beginning, as I put in the picture, there's a lot of roads that we have to go through and it's not a straight pathway. So what is the difference between always I get when you're a fellow, you want to go or a resident, you want to go to academic medicine and they say, no, if I go to private practice, I will never return. That's not true. You can go to private practice or to hospital base at the beginning when you're doing it, if you're doing a waiver, a waiver, but then you can come back to academia. The only thing is that during those times you have to keep scholarly active. So the difference between academic environment and what is a non-academic environment is basically that in academic environment, you have a little bit of more things that need to be done. For example, scholarly activities. And it doesn't mean exactly research if you are doing research grade, but it means that you have to do quality improvements and health equity, things like that. And you have to educate. Meanwhile, the non-academic environments are mainly based on clinical things. If we think about how academia looks like today, it's very similar. They hire you for being a clinician that teach and they don't give you any protected time. So the difference between academia and this is just that you have a, uh, an affiliation with a university or school of medicine and in the others you don't, but it's your preference. We need academicians. We need people that take extra of their time to educate the next generation to, uh, to do produce the research that at the beginning where you are not funded is a little bit more difficult, but we need that. And we need the clinicians. We need the expert clinicians that are expert in a field that will, that will treat all the population. So, so I just wanted to clarify the difference between the two of them. And in academia, there is certain levels and you're, you're aware of this. There is instructor, assistant professor, associate and full professor. Uh, uh, and then if you're in an environment that is not an academic environment, most likely you can be a junior partner or associate consultant, a senior partner or a senior consultant or a full consultant. So, so these are just different terms that they use. Uh, uh, and depending sometimes you can be in a community hospital affiliated or giving lectures to, uh, a medical school and then they will give you a title of adjunct. So we'll be adjunct assistant or adjunct associate or adjunct professor of medicine depending on, on, on your rank. Let's go now to the different visas that we can have. And this is a, just some of them, uh, probably it's a little bit different for scientists, but in the clinical world, uh, we have a J-1 visa that is a training visa. Important to mention about the J-1 visa is that the J-1 visa is not paid by any hospital. It's paid by us. So we have to pay to the ECPMG. The cost of the visa, the ECPMG deal this visa directly with the Department of State. And this visa allows you to, is a training visa, allows you to stay seven years, uh, in the country. The, why I mentioned this is because, uh, uh, I was last week in the AMA meeting and one of the presentation from the AAMC says that 30% of programs director don't look at IMGs. They don't open application of IMGs, 30% of the, of the programs director and 50% of the programs director say yes or no. So it's not that they open IMGs, it's yes or no. And 20% they open IMGs. And why is the main reason is because they think that they have to sponsor visas and the visas cost a lot of money. And we were talking about H-1 that cost money for the hospital and they don't understand. And we need to get a campaign that a J-1 visa is not paid by the system. It's, it, the applicant need to be valorated for their application and not for the immigration status and not for the IMG or U.S. medical graduate status. So here I tell you, after you finish your J-1, if you want to stay in the country and probably 75% of the J-1 visas holder stay in the country, you have to do something called a waiver. Many of you know about this. And this means that you have to go to an underserved area or an area that have a lot of Medicaid patients. And this will change from time to time. There is a new bill that has been introduced in the Senate with Senator Klobuchar. She wants to increase contract 30 to contract 50. So to give 50 opportunities per state for doing this waiver. And here I mentioned this because really many of the state are struggling with physicians. We have been in a world where there is other healthcare allies that are being doing the work of physicians because we don't have enough physicians. So there is an opportunity for growing the international medical graduate. Meanwhile, I think we will, we work in the pipeline to bring that group of people from the, from medical school. And then the other thing that we bring to the table is the diversity that we have among us. Diversity on gender, race, ethnicity, country of origin, many, many diversity that, that is important. And here I want to mention that nowadays there are certain state, um, the most important one was a bill that was passed in Tennessee, uh, last week, two weeks ago, that, uh, they are asking, uh, well, the bill that now law is, uh, um, what is considering is that you, if you did a training in your country and you work for three years in your country in that specialty, you can come to Tennessee and take them board of internal medicine, take the board of endocrinology and practice with, of course, with a USMLEs, first USMLEs, and practice without doing residency. There is some... I think that's one of the big differences. Yeah, yeah. And this is a J-1, when I mentioned J-1, it's J-1 clinical, because J-1 research is what it's mentioned. It's a totally different visa. And then the law in Tennessee is allowing that. But then the unintended consequences that we need to think about is, you have to have a contract. Who will hire you if the payers at this time do not pay for people that are not board-certified prior to entering your contract? So it's more complicated. But this is happening. And this is happening in many states. Utah is coming with that. Nebraska is coming with that. And I imagine that this will spread among the entire country because they need more physicians in all of those states that have the high-issue rural areas. So how do you prepare to get a job? And I always tell the fellows that you have to start in your first years of fellowship, usually between April and June of that first year of fellowship. And when I do my fellows, I always give them the permission. I have to talk to the rest of the system because they don't understand why a person is looking for a job, even not finishing the first year of fellowship. But you have to start your process at that time because you need to have all your process ready and your contract, everything signed, so your lawyer can introduce that for the contract study by October 1st. And there are some states that are very, they fool. They get fooled very fast. For example, one of my friends, she submitted at 8.03 the publication for Texas. And she was the 29th on that list. So it has to be, sometimes it's luck. But it's very important that you have all this process done before October 1st when you're getting your first job. And important here is that when you are dealing with a lawyer, the lawyer has to be a very good lawyer that understand J-1 waivers. And many of the things that happen there is that you provide a lot of the things that you have done. Very important that at least during the residency and when you start your fellowship, work in scholarly activities. Because that will attract more the lawyer to write different letters that they are going to do to get you your waiver. And this is increase your scholarly activities, your visibility across many things. So in endocrine, we come here, present posters. But there's other areas, academic medicine, the ACGME has their annual meeting where you can present things in education. There is a group called Building the Next Generation of Academic Physicians that if you want to stay involved with academic physician, Ben Gap will help you, will guide you, will mentorship. There is other groups, WMC has their meeting. So increase your visibility in all these areas depending on what is your area of interest. If your area of interest is a specific research in a specific area, then go to those societies, go to those meetings so you expand your area. And when I mention scholarly activity for clinicians, this is not being a research that is published in New England Journal of Medicine. Nobody expect as a clinician that you have been three years in residency and two years in a fellowship. If you are not a PhD or MD-PhD, they don't expect that. What they expect is that you have been active in case reports, quality improvement. If you have a research mentor, yes, in that research mentor, but you know as a clinician it's very difficult in residency to have this great publication. Sometimes it's possible, but not all the time. So just scholarly activities is more than that. And now we are bringing the scholarly activities leadership positions. So if you get involved in committee of interns or residents in your institution and you get a position there, that is considered scholarly activities. And as a program director level, the AAIM, the Alliance of Academic Internal Medicine, that include all the subspecialties, is considering that very strong. As I mentioned, it's very important to have a mentor in this process because it's complicated to navigate, it's not easy to do it, so mentoring I think is a key role. Doesn't have to be a research mentor. We always focus on our research mentor. Yes, your research mentor is for research, but there is career mentor, and if you can find a career mentor or multiple mentors that are international medical graduate that can help you and say, you know, going to that place, then this and this, or that place will not accept your visa, then you have to transition to an O visa, that that's another pathway, then it will be very important to have. How do you seek good mentors? Basically, you have to find a person that is willing to take some of their time to guide you, to a person that you think that will guide you, I'm talking more about career mentors, a person that aligns with your career goals, that can speak about your career, and that can introduce you to people, like in this meeting, can introduce you to others, so the others can know you, and then you can connect with others and start building your network. Network is the other part of very important, I always tell everybody, and more as an international medical graduate is, when you come to these meetings, yes, go to the sessions that are important for you, but the rest of the time, spend in meeting people, because those peoples are the peoples that will guide you to the next level. Those peoples you don't know, your peers here are probably 10 years from here, 20 years from here, division shift, department chairs, and then if you want to take a next step in your career, then you already met them, and it's easier to connect to a mentor whenever, or to a person that you met in another place than just sending an email, so the part of doing this here is very important, they can write you letters, very important when you apply for the next step in your academic career, you need sometimes, for example, for a professor, I did 12 letters of recommendation of people that have not worked with me, that have not published with me, that are not in my institution or my prior institution, so it's many characteristics, then you're like, where I can find these people, and you find these people in these meetings, because they know you, and then you ask them, hey, can you write me a letter, and then yes, but if they don't know you, they will not be able to write you a letter, so important for searching jobs, always be yourself, the big issue that we have with the J-1 waivers is that there is not a place that just focus on J-1 waivers, so you will get, when you are in this process, when you're finishing fellowship, or if you finish in residency, you will get a lot of places, a lot of offers, but they never disclose if they accept J-1 waivers, H-1 is a different visa, H-1, they will most likely accept, H-1 is paid by the hospital, so H-1 is different, but J-1 waivers is very complicated, so the best way to find this job is to have a mentor that understand, and usually, for example, in my case, I get a lot of J-1 waivers opportunities because I have been involved in this for many years, and then I usually try to spread the word to see if a person wants to go there or not, but searching for a job is not an easy job, I can tell you my personal experience was when I was looking for jobs, I went to several places, and one of the things was I went to one institution that I was very excited, I did everything, the interview, they hire me, I signed the contract, and one week later, I receive a phone call and say, oh, are you on a visa? And I'm like, it's in my CV, yes. Oh, our state cannot sponsor visas this year. And then, you know, how you feel, you spent all of the time trying to go to an interview, you get excited that you have your first job, and boom, even if you sign the contract, they cannot hire you. So it's very important that when you search for a job, the first thing that you have to do is, the recruiter, sometimes they don't know it, the chief of the division, they don't know it for sure, you have to talk to human resources, and human resources will tell you, oh, yes, we can sponsor, we cannot sponsor J-1, so you don't take more of the time of getting an interview if they say they cannot sponsor. H-1, as I mentioned, is totally different. And then, if you want a different pathway, O-1 can give you a pathway for doing research if you are a clinician, but the problem with the O-1 is a five-year limit. If during that five year, you don't do the outstanding research that they are looking, then you have to go to a waiver anyways, so they just prolong your waiver time. That's the only thing, they prolong the waiver time. Some fact sheet of academia, really, the ideal world would be that you have some protected time for research and education versus your clinical time. It depends on the institution. If you go to some of the big institutions, most likely they are going to give you 80% clinical, and that's almost 100% clinical because of all of the things that we have to do after the visit, but if you go to a small institution, probably they will be allowed you to do more of the things that you want. Location is important. Sometimes, yes, we can talk about this, but if you have family preference and you have some place that you want to be, then location will be top. Always validate your social life more than the others because if you are happy in a place, you will stay in that place. Some of fellows that I had, it was like, you know, I am not married. I want to find a partner. I don't want to go to the middle of nowhere because I will not find anyone. Even if it's a good job, but there's different perspectives. So think about your life. I think that sometimes when we are resident and fellows, what we think is just the next two or the next three years of our life, and that's not true. In life, you have to think what is the next 10 years of our life and what is your goals in that. As I mentioned, you can start in private practice and move to academia. That's not a problem. I know many people that have done that and have been very successful and now are publishing more than people that start in academia and stay in academia. You need to start building your future since the first day of fellowship. I know that it's difficult during that first year, but you need to start that. You need to get involved with opportunities in education in the fellowship so you can start building that portfolio. And then there is certain different pathways. For example, there is, if you do the waiver, some states will ask you to do 50% of your time as primary care. If that is what you want, that's fine, but if that's not what you want, don't look at those states because there is, in those 30 spots, depending of some states, they give you like eight or 10 spots for what they call flex, and those flex are for specialties. The rest is for primary care. So you have to look carefully. The other, some other state has more flex so that you can have... When you're going to interview, very important is the connection with the person that is interviewing you. The recruiters will always tell you yes, but the recruiters are not the ones that give you the offer. So the ones that give you the offers are usually the places where you interview. If there's a lead of the group or if there's a chief of the division, those are the people that just connect, follow up as you did with residency and fellowship, follow with a thank you letter, be sincere, express what is your interest from the beginning so they understand that this is your interest, and if that interest align with them, it's better from the beginning say, you know, oh, I am interested in doing research, and they say, well, we're a clinical. So then why go to that place? So from the beginning, be very sincere, and then always review your contract by a lawyer, by a labor lawyer, because sometimes people say, yo, no, you're on a visa, you don't have way to negotiate things, and that's not true. We have a lot of way of negotiating things that things is that we don't know. So then that lawyer can tell you, you know, they're offering you, sometimes there's an abusive system to a J-1 visa, they offer them 30,000, 40,000 less than a non-J-1 visa, and then you are like, you can negotiate that kind of things. Not every job is like that, but some of the jobs are like that. Deadline, October 1st, still October 1st, there are some places that have Delta waivers, like Alabama, south of Illinois, that they never stop, so there is no deadline for that. There are some places that just follow the contract 30. Now Florida is having Delta waivers, but usually it's 30 spots per year, if it's not part of the Delta waivers. So you have to understand that, yes, even though we came with a lot of ideas of doing other things, the contract 30 make you do 80% of your time clinical. That's as per the law. So you can negotiate that in a different way that the system can do it. At the beginning of my career, I was on a J-1 waiver, and I did 60% clinical, and they were able to negotiate that because of other things. So you can negotiate that, but the expectation is that 80% that you have done that, and always appreciate your family, because that's important in your life, and then go to IMG-friendly jobs, so places that have other IMGs there, doing the waiver and things like that. And just finalizing a personal experience, so I'm originally from Panama, so I did my medical school there, and then really was not exposed on networking during medical school. I was not exposed on marketing myself, and when I came to the US, I realized how important is those two things. So I was very interested in academia and research. I have some of a background. What I had was a very clear objective of what I want to do in my career, so I started getting involved in multiple organizations, and those organizations helped me in my future. One of them, the Endocrine Society, but those organizations opened my future for the next, my first job and my upcoming jobs. And I mentioned this in our prior panels with Flair and with others, is this is the time to start networking. This is the meeting to start networking, so I hope that at least one of you look by your side. If you don't know that person, ask them for the email, Twitter, Instagram, Facebook, whatever is available, and start talking to that person. When you find people here, it's not that you will send emails every week. Sometimes it's just once a week for holidays and say, happy holidays. That keeps you in contact with that person. Get involved with multiple opportunities that the Endocrine Society has. Get involved with committees or special interest group. Just enroll them. You don't have to sometimes spend a lot of your time, but then you get visibility there. And then nowadays, we have social media. And I met many people through social media. I came here and, hey, Ricardo. I'm like, oh, we are friends in Facebook. I'm like, oh, and then that's it. So I connect with them. And then sometimes these people are of the same interest, research interest. Sometimes these people have the same career pathway, and it's very important. And I just want here to prompt a little bit. If you are looking for a J-1 waiver, the Cleveland Clinic has an opportunity right now for a J-1 waiver. If this is the stage of your career that you're looking for a J-1 waiver for next year. So everything that is possible now start out as impossible in the past. And I like that phrase because everybody told me, oh, you will never get an academic job because you are on a visa. And that's not true. I was able to be at the University of Arizona and grow my career exponentially in an academic job, and now I'm at a different institution where I continue to grow my career. So it's not true that you cannot, if that is your goal. Not everybody needs to be in academia. There are people that can be in clinical, and that's perfectly fine. But never be this decreased because if a person tells you you will never achieve that. That's not true. You can achieve anything that you put in your life. And with this, I finish my presentation and get back to the chair. Thank you. Perfect. Welcome. Why don't we do a quick elevator pitch of sort of your international background and then open up to the floor. So I see a beer. Go ahead. Okay, so good morning, everyone. My name is Antonio. I am originally from Brazil. So I had my MD and PhD training originally there in Brazil and then I practiced there for 10 years in a public hospital that do lots of research. And I had an opportunity to come to the US 10 years ago. Our institution in Brazil and University of Michigan had like a established research partnership. And then I came here under the J-1 visa. My original idea was to stay just for a year, but there was a big project that was going on. I do research in adrenal cancer, it's very common in Brazil. So we had a lot of clinical experience there. And here my focus was on understand a little bit more about the molecular pathogenesis. And my personal goal was to learn a little bit of bioinformatics. And that's how things started. I was really good in doing that. And it's kind of an unusual career because after being practicing as an MD for 10 years, then I completely switched my career path. And then I was invited to stay longer in University of Michigan, start getting involved with more things, doing more research in the area. And then I just, things just happened as the day went, right? And then I decided to stay here in the US as a permanent position here. And here I am now, I'm looking in the past for my independence and doing research. And yes, so that's my background. Yeah. Can I ask you a question? So you did clinical medicine in the US, you did residency and fellowship also again, or you're doing just research? I'm doing just research. I don't see patients here, just research. Great. Thank you. Okay. Good morning, everyone. My name is Claudia Ramirez. I'm originally from Peru. I was born and raised there. And then I did my medical school in Peru in one of the universities that have a clear, a clear medical school in Peru. In one of the universities that have a clear path for medical students to go to different places. The two main places are Spain and the United States. So I kind of had an idea that I wanted to come to the United States from the beginning. So I graduated in 2011, and then I came to the United States to do a combined clinical and research clerkship. The research clerkship was three months. So I was able to have develop a poster and abstract that I submitted for an international meeting. And it was there that I met my former mentor. So I totally agree with Ricardo that it's very, very important to network in these kind of meetings. And then, so after that, she recruited me to Vanderbilt University, where I did clinical research for three and a half years. Initially, I started, I thought it was just an stepping stone, but I ended up liking clinical research more than I expected. In the process, at the end of my first year of research, I decided, I always knew that I wanted to do clinical work as well. So I started studying for the USMLE boards, and then I got my ECFMG certificate. But some, there was actually, there's a large international community there, especially, mainly in research, actually. And several of them were actually Peruvians like me. So they had done the national interest waiver, and they were the ones that pushed me to do it. At the beginning, I thought it was like impossible because it was like so many things, so many requirements, but I finally met with the lawyer, and the lawyer was like, no, this is doable. And she encouraged me, and I was like, okay, maybe I can do it. And then I involved my mentor from the beginning. She was, she is a very well positioned, and she's currently the dean of Vanderbilt University. And she's currently the dean of medicine in a very well-known institution. So she actually, even though she is from, she's an American, so she was not familiar with the process at all. So I had to explain the process to her, and I involved her, and she actually helped me because out of the eight letters of recommendation that I needed, seven of those, no, six of those, were from her colleagues. And just by approaching them and saying, and I met some of them at meetings, but some of them just knew me by name because they knew that I was working with her. So she definitely helped me a lot in the process. I also had a letter from my PI, so from her, and then I asked for the CV of all these people to kind of like portray that they were actually very important in the field, and that they were supporting my application as a scholar in this country. So I started the process in 2013. So I met with my lawyer February 2013. I signed the contract. At the time, it was much cheaper. So she was charging me $6,000 at that time. So it's been 10 years now. So my understanding is that the price has gone way up now. But the nice thing was that I was paying $400 per month in like nine months or so. And then that was like 4,000, and the remaining 2,000 was once I got my petition approved. So that was a nice thing because I didn't have to pay upfront the whole thing. And it's always important to remember that the first meeting with any lawyer is usually free. So you don't have to sign a contract right away. You can shop around for lawyers. And like Ricardo mentioned, it's very important for you to get a good lawyer that has experience with the process because there are many different pathways. And so every lawyer has their own specialty like we do. And then, so I signed the contract February, and then we submitted the application December that year. And then I got my, we submitted also for a parole, so that a working permit and a parole because I was actually getting married the following year. So it was very important for me to be able to work, to travel back and forth. So I got the parole like four or five months later, and then my green card actually came in October the following year. So it took about two years almost from start to end, but it was definitely worth it. Like Ricardo mentioned, there were some, there are some places that don't even consider J-1 IMGs. So actually I landed in a residency program that only took green card holders or citizens. So had I not had my green card, I wouldn't have been able to be there. And so, yeah, so I finished my residency training in 2019. I decided to stay back a year for chief, and then I applied for residency in endocrinology. Finished my endocrinology training at Baylor last year, and I decided to stay again one more year for research. So I'm actually going back to research now, but it's more like bench research. So, and then I'm starting my first instructor position at Baylor in a couple of weeks. So I definitely believe that it's not a straight line. There are multiple pathways, and you can go back and forth between just clinical work and research, academia, or industry, whatever you want to do. You just have to keep focused and engage with other people because that was the main thing for me, like having people, talking to people that had done this before, and then involving my mentor at the time. So, that's about it. Thank you. And the other thing, right now, you're already... Can I say something about all of this, all visas, or when you're applying for your green card for EB1 or EB2, always we think that these are like people that get the Nobel Prize, and that's not true. I have written many letters of recommendation for all visas and EB1s, and the lawyer make that letters look amazing. So the good thing about writing those letters is that you only have to put your thing in the second paragraph and then sign it, because the lawyer did the rest, and make like, you present here. They present it in the most important conference of endocrinology in the year, and this is the title of the presentation. The people that are looking from the standpoint of immigration are high school people. So they don't understand what is the, that is a person that is presented internationally and is well known, or a person that is not. So never, never let that not throw away, so that your application, I agree, you build your portfolio, and the lawyer will see on all of that things, like all of the important things, will write a good letter. So that's why you have to have a good lawyer. I had a bad experience with one lawyer that gave me, like, I pay a lot of money, and he want me to write all the letters and all of that, and I was listening to my friends, like, oh no, my lawyer wrote all the letters. So the lawyer should write that letters because they know what the immigration people are looking in that. That first consultation with the lawyer should be brief. If it's not, don't go to them. And to pay I think half up front, and if I... Ask your friends, that's how I find them. Thank you so much for this. I'm like feel identified. I have like can I ask like two questions? Yeah, so I was I mean I came I I didn't know how important was networking and was really late So I realized oh my god, like a one friend got a b1 and then she said Maria you should apply for a baby Well, I mean you have a better and I apply but I mean now it's like I'm applying for fellowship like next month and I don't know how to If I'm I'm fighting premium processing to try to see if I can get the approval But I don't know how to introduce my application if I will need I will need visa or I won't need visa So I will really appreciate your feedback in this and the second question I have is I have the same experience as you dr Ricardo my lawyer my first lawyer was horrible I ended up doing my own and I don't trust him now So can I choose which my lawyer and it's not any trouble in that like, thank you. I Can I can answer the first question? So at this time the only time that you can mention that you don't need visa is if you have your green card in your hand up to that point we are bringing a One of one person to work with me at the Cleveland Clinic he is a he's a Colombian endocrinologist and He applied for EB1 as premium and all that but up to now he has not get at it So we not a sponsor in the h1 visa to him Meanwhile, it seems that he's going to get it but if you don't have it in your hand, you cannot say that you don't need visa because The the program need to find the way that they need to sponsor because you have to start July 1st So if during this time because you are applying this year, so if during this time before July 1st of next year you get the visa or before the ranking list in February You get the visa you say a little bit you get the green card Sorry, you submit a little bit an email to the programs that you like and say oh, you know my status switch I don't need visa anymore. And then but that that's very important from from the beginning to stay because the programs there are some programs that will Need to start working on this since they interview you and other programs will not accept any interviews Even though you have a possibility of getting it For the second question So, I think it's very tricky once you sign a contract Getting out of the contract, but it's not impossible. There are like Possibly you could Talk to a lawyer another lawyer, of course And then ask him. Hey, do you think there is a chance that I can get out of this contract and then start working with you? Unfortunately, your case is not unique I I know a bunch of people that didn't have a great lawyer. Actually mine wasn't that great either but Because I also wrote most of my letters, but I decided to stay with her because I mean She had a good success rate. So I was like, yeah, I mean I already started so I might as well finish but Another colleague he was like no, I'm getting another lawyer So they can always find like the like the small print line and get around it But definitely consult with another lawyer Yes Thank you so much for that amazing lecture. I wish I had heard it you know a couple years ago but I'm a fellow at UChicago finishing up and I'm gonna start my waiver so I I'm ready. Thankfully I got it through the CONDRA 30. However I did some clinical research and I'm really interested in going back but my current waiver is gonna be a hundred percent clinical and it's really like have four and a half days of clinic so it's like so hard in my mind to add the scholarly activities as Dr. Ricardo was mentioning so I was just curious do I really need to have like actual publications during those years like you know and how is the transition like how can I get back to academia I know that you said it's possible and I have also heard like you know it this is not possible so I'm glad that you shared your experience. Yeah so so I can tell you one example I have a very good friend I was doing my work in an academic job when I start and then she was not in the main campus she was 45 minutes away in Newport Rhode Island in the middle of beautiful city but very far away. What she did what she continued the connection with Brown University this means that she was connecting for the Grand Rounds at that time was in person so she drove the 45 minutes now is virtual so so she connected and then she was talking a lot with the chief of the division so she can continue hey you have a case report or the fellows can rotate with me and some fellows wanted to see so how rural works and then they went to her so during those three years what she did was that when immediately a position open at Brown she was the one that was higher because she had all the experience so another friend of mine also Brazilian she did in South Massachusetts her her waiver she trained at the Jocelyn BI program she continued connecting with the Boston people immediately she finished she went to Jocelyn now she's a diabetologist in Jocelyn clinic so the only thing that you need to do during those years is continue your relationship with doesn't have to be your program or it for example close to the place that you are probably close I say in a radio there is an academic place and then just introduce yourself say you know you have to negotiate a little bit because sometimes Grand Rounds or presentations are in times that you have you have to give the extra that's the thing with the IMGs we we have to give that extra thing if we want to fulfill our dreams so you have to give the extra go talk to them say hey if you need any case report I can help the fellows or any research I can contribute with the research that you are doing from my place and all of that and that will open the doors again back to academia so it's not true that those three years you throw it away no just the people that throw it away is the people that do not want to get back to academia and they just focus on clinical and that's perfect but if you want you can leverage your pathway and connection and they you go back again when you get your green card to academia again thank you for the insightful presentation my name is Samuel I'm originally from Canada and I'm gonna be a second year fellow at Marshall University in West Virginia my question is if the panel could maybe highlight the differences a little bit between the National Interest Waiver and the J-1 and the implications of it thank you okay yeah so I think for the J-1 waiver I don't have any the clinical J-1 waiver because the the research is a little bit different but for the clinical one like Ricardo was mentioning you have to do those three years and then depending on which country you're coming from so while you're doing your J-1 waiver you get an H-1 visa and then I believe towards the end of your waiver you adjust your status and you submit the paperwork to get your green card but the time frame between actually applying and getting it varies by country so it depends how many if there is like a lot of people coming from your country it may take longer so whereas with the National Interest Waiver it's usually a fixed time that you can actually track online on the website there is there are the processing processing times and you can track if you submitted your application by this date you should hear around this it gives you a time frame and so you I feel like you have a little bit more control over it the other difference is that as a National Interest Waiver pretty much you are sponsoring yourself nobody sponsors you unless it's a different situation but for me I was sponsoring myself so I had more control over it whereas sometimes with the J-1 clinical waiver it's more like your employer controls the process it's their lawyers so sometimes they may not have your best interest and they kind of like hold you to it so I feel like there are definitely pros in doing the process yourself yeah and I will for example if you ask me a question I would recommend that people that come from India Pakistan and China if it's possible to do more National Interest Waiver will be better the backlog right now for EB2s is 75 years we are fighting about that at the AMA so there is we have kids from those doctors that still on H-1 the kids were on J-1 because until 18 now the kids are without status because they've got more than 18 years old even the parents have been practicing the entire time in the US and they both they were not born in the US but they came with their parents and we are dealing with this is that we call DALCA not DACA but DALCA the the ones that came legally to the US and now the kids are not having so so if you're from those country if you are for Latin America Europe you will get it it's it's they have a certain amount of spots it's not I have not heard people that don't get a big of a spot but for the Asian countries yes it's important hi I'm Kate Ward a postdoc at the University of Utah most people that I've heard going for their green cards at my Institute are sponsored so there's not many self petitions and I'm wondering in finding a good lawyer can you pick one from any state like do they have to be like where is the application submitted to is it like a federal is it something to the whole of us okay so I can find it I can get a good lawyer that someone recommends from New York and use it with the University of Utah okay yeah okay yeah right okay okay great thank you are kind of really the cream of lawyers. But again, within that group, I found some of the lawyers have a huge success rate and a really strict criteria for taking IMGs in for applying their EB-1, but there are others who are flexible and really encouraging. So I approached the top-notch first, and they rejected my application. and IMG in a way that, you know, you can make it stronger. So definitely join that group, EB1 for Physicians. It has all of these questions and, you know, success stories, rejection stories. So yeah, thank you. And it's not only for physicians, it's also for PhDs and scientists. One more thing, going back to your question. So after I got my green card, actually, my husband was on a J-1 clinical, J-1 visa, actually, finishing fellowship. So somebody, we were living in Tennessee, we met with friends in Georgia, and they recommended a lawyer, and then I don't even remember where he was, but we never met him in person. It was only by phone, and his paralegal was very good, and she kept sending emails, and we were always in contact. But, I mean, we did the hardship waiver for my husband, and it was very hard. Also, his file was like this big. We also needed a bunch of letters from people who knew us, but at the end of the day, it worked. It was, I mean, it was expensive, yes, but, and the other thing is that he was not able to work for a year. But yes, you can definitely have a lawyer that is out of state. And can I tell something extra about the, several things that need to understand, and probably you know about this. One is that if you are on a J-1 visa clinical, and during that time you get married with a US citizen, that person cannot ask you for obtaining a permanent resident. You have to finish your waiver, or do a different type of waivers, because that will not work. So if you are in the process of getting married, do not come with a J-1. Get married before, and then obtain your green card, and then come to the US, because if you are here, and then you get married here, and then they cannot ask you for it. And the other, that Claudia mentioned, was the hardship. So hardship is another way of obtaining a waiver. It's certain criteria. Some of them is that if you get, you have a kid in the US that was born earlier, and they require a little bit more attention, a lawyer can justify that that is, US citizen was difficult at the beginning of their life, and need care for the rest of their life, and you can get a hardship like that. So there is other condition, other type of things. So the lawyer will tell you, yeah, it classify or not classify for hardship. Yeah, it's both for citizens and green card holders. So if your partner, if, for example, for me, it was something silly, and you are going to laugh, but I have asthma, and I have anxiety, and so that was the basis of my case. I was like, if my husband has to return back to Peru, there is a lot of contamination in Lima, where I'm from. So if I go back, I won't be able to perform as good as I am here in the States. Or if he goes back and I'm held here, I'm going to be suffering from anxiety. So it doesn't have to be like a life-threatening condition for you to apply on the basis of medical stuff. So we built a case, and he got his green card. I wish you told the story, Claudia, to me earlier, so I could pull the case of hardship waiver. But anyhow, so thank you guys for holding this session. It's very helpful, and I really wish this was happening last year when I was here at Endo in Atlanta. So I think one of the challenges that I'm facing, and Claudia is a really good, close colleague of mine. We graduated from the same fellowship program, and is finding letter writers, right? So even though I've been kind of a social person networking at meetings, endocrine society meetings, and in this meeting itself, I found it hard to network, despite being on multiple Facebook groups and being on ResearchGate and stuff like that. One of the hesitations that I have found is that the attorney wants, nowadays, I'm an Indian, so for us, through regular process, the wait period for green card is 15 years or so. So we have to self-petition, otherwise, there is no way out to fulfill our dreams. So they are saying to get independent letter writers. So what that essentially means is I cannot ask anybody that I am directly affiliated with, like my residency or fellowship institution, so I have to ask for letters outside of these institutions. And it has been a real challenge, because people cannot attest to your work when you're so early in your career, saying that this person is going to do a groundbreaking research in the next few years, or is currently doing it. So navigating that, I feel like approaching so many people, Dr. Ricardo Correa has helped me, Claudia has helped me make contacts with a few, but again, the attorney wants seven to eight letters, and even though they are writing these letters for me, but finding a person to kind of sign on a legal document, when you bring this up to them, there is a lot of hesitation. So I don't know if the endocrine community can be made more aware that we are all like a family, and we're not asking them to do anything that's illegal, because within our endocrine family, when we approach people, I feel like, what is it that you're asking me to do? Is it a legal document? Then they take a step back. And so I think that's where my biggest challenge has been. So I've been able to find three or four letters, but really struggling now to find outside. Yeah. So my biggest advice is to use the pictures or have to reach out. I see. Ladders. You know. I totally agree with that. I think the mentor and it doesn't have to be necessarily the mentor that you work with at your previous institution. It can be like like a peer or another mentor that you or a colleague that you you think it can help. So anybody who can help and especially I think if somebody has gone through this process before and they can vouch for you, I think that's that's probably. I think it's mostly the physician IMGs who have gone through this process that I'm kind of hunting for. That's what Dr. Correa advised me to do. So yeah but it is you have to be patient because I'm still kind of anxious all the time like who do I have on my list so I'm just trying to find more ways to kind of approach people. Yeah and that's mandatory. So they usually like people that just review your CV and then they testify that you are amazing by just reading your CV. That's that's what the lawyers are trying to look. But I totally agree with you that there is we need to start teaching the non-IMGs about these struggles. So it's great to have this session here but I mean that everybody here is an IMG or international scientist so where is the non-IMG that want to listen to this kind of things and then we need to make a little bit more pressure to different societies including endocrine societies. Hey we have this session not 8 to 9 30 on a Sunday. And then bring program directors bring chief of the divisions. For example Karini that has been a chief of the division she knows this now because she's an IMG but not every chief not every program director know about this and this is our career and if you they want to help us that we represent 25% of the of the workforce we need this kind of things. And I think I really liked because the Facebook endocrinologist group was one of the platforms where one of the you know other physicians asked for a letter and that gave me the courage to ask for the letter openly on that forum because I was hesitant and I think a lot of them then approached me hey what is this for. So yes we definitely need more society and more platforms and sessions like this to kind of advocate for us and understand better. Thank you so much. Oh and then one more thing very quickly so I know the lawyer is probably going to put pressure to find letters from like the stars in your field but it doesn't necessarily have to be a star really. I mean I think like Ricardo mentioned the people that review these applications are people who graduated from high school I don't think they have much instruction so you can play with I mean they different definitely pay attention to where is this letter coming from if it is coming from Stanford or Yale they are probably going to be like wow this person is amazing because it has like letters of recommendation from people all over the country but it doesn't have to be a Nobel Prize. Yeah I wrote a letter in my first year of faculty and the person got the green card. I was nobody. It doesn't matter if it is young or old or whatever as long as they have an academic position I think that's good enough. So, these also have them for you to... So, AFM's own little space is in here. The only difference from academia and this is that in academia you say I want a promotion to the next step and it's not but what here you say well this I will send it to immigration and then people is like oh this is the government immigration and that's what they get afraid because they don't understand that this is the same thing but that's that's the problem that we're having with when you mentioned immigration they say like if No. And plus, the worst scenario is that they say, no, I'm sorry. That has happened to me, actually. And I'm like, okay, thanks anyway, blah, blah, blah. Or somebody, one of my recommendation letters came from a person that said, I typically charge for these kind of letters, but because you are the mentee of this person, I'm not going to do that. And I said, okay, thank you. Oh. Yeah. I would never pay for a letter. Yes. Pay your lawyers to write your letter. But someone signing it? Yes. That's probably illegal. Yeah. Probably illegal. Yeah. Probably illegal. If not illegal, unethical. Yes. Unethical. Yes. Yes. Probably. Any other questions? Sorry, this is a very specific question, but I've heard that whenever you start a waiver, sometimes the timing of the green card application varies. I don't know if there's any advice, I think, from Dr. Ricardo, how to ask your employer, like, are there any ways to press on that? Or like, will I need to also consider applying for a national interest waiver from, you know, whatever my clinical research, if the employer is not really, you know, going forward with the green card? Yeah. I think that you can do the two pathways. It's not overlap. Oh, okay. The lawyer will guide you. But for the persons that are on a clinical waiver, probably during the second, beginning of the second year of your job, you start asking that, and you just hire the lawyer. I think that you are in the second year of your job. Yeah. So, I don't know. Yes. Yeah. What I've heard and what I've read is that I have to be in the second year, right? Or starting a year. So you're on J-1 visa now, research, transition to a J-1 visa, clinical, and you're doing, you are in what stage of your career? You are going to residency? I am going to do fellowship. To do fellowship. Okay, so then you have to wait until your residency. Yes, so you are going to do the fellowship. Then, I don't know for pediatrics, but AVIM, the American Board of Internal Medicine, will not allow you to do fellowship with that. They will not be, you will not be board eligible if you don't do your residency. The same thing. Oh, sorry. Less years where I have to. Okay, yes, two years, yeah. So then you have to do your fellowship. Then you have to do your residency. And then at first year resident, because it's two years of residency, that first year resident, you apply for your waiver. Yeah, it's at that time. Because then you can get a contract during that first year of fellowship. Because now you are board eligible, to the residence, sorry. You are board eligible for American Board of Pediatrics. And then the contract, any hospital will contract you. Just to clarify, were you talking about the J-1 visa waiver for research or for clinical? She cannot do research J-1. She will switch, whenever you are on a J research, and you switch to J clinical, that's it. That's the end. You always will be J clinical. You have to do the eCPMG. You will see that in the bottom of your visa, it says submit to two years going back to their country. All of the J-1 clinical. The eCPMG sponsor have that. But you don't have to do research J-1 visa waiver before switching to a J-1 clinical? No. Okay, got it. You're switching to a clinical. The J-1 research, it's totally different. But if you choose to switch to a clinical, that's your stock. Then the waiver is mandatory. And how about the timing? Isn't it seven years for J-1? Clinical. Yes. Yes, it's a seven year. How does it count the one year to do the research? Research is different. It resets. It's called the same letter, but it's totally different. J-1, let me tell you a little bit of the story. J-1 clinical start in 1965 by the Department of State with the collaboration of the eCPMG. So it's a training specifically, and it's a division of the Department of State division that had the J-1 clinical. You cannot go to the eCPMG and say, I want to do waivers. Because the idea of creating that visa was to, that you have to return to your country. So that's a different time. Every time, and I'm disclosed, I'm the eCPMG board of director. And every time I ask a question to the eCPMG, hey, the waivers, it's not my problem. Because the training part is eCPMG problem. But what after training is not eCPMG. That's you decided to stay in the country. So that J-1 clinical have the same letter, J-1, but it's not a J-1. It's not a J-1 that another person in law year or any other area will get it. J-1 clinical is a specific visa from the Department of State that is managed by the eCPMG and the Department of State. So every time you get into that one, the others, no, but into that one, there is a requirement of two years to go back to your country, or now we call waiver here, but it's a requirement. So any time that you enter, if you were in an H-1 in residency, and then you change to a J-1 in fellowship, boom, again, you enter to the J-1 problem. Yeah. Just for you guys to have an idea, the J-1 research waiver is usually, what I've heard, I didn't have to do it for some weird reason, but what I heard is that you go back to your country and you go to the Ministry of Education and you ask for a letter, and they basically have to say, yeah, we don't need this individual. He can stay in the United States. And so that's it. That it's just a letter saying that you don't have to go back home. That's it. Yes, that's, in Spanish, I don't know, but in Spanish we always call, and this is just a joke, in Spanish we call that the visa jodida, because you're screwed every time you get that visa. But well, that's the way that it is. Once a J-1, always a J-1. Correct. Yeah, that's the same, yes. Okay. Who asked you? Yeah. Okay. So she first went to her police assistant and he said, Yeah, the worst they can say is no See you in class!

foreign medical students

medical practitioners

scientists

U.S.

panel discussion

practical tips

visa and immigration system

networking

mentors

professional network

J-1 visas

National Interest Waivers

application process