Applying to Residency as an International Student at a US Medical School

By Yoshiko Iwai

Part of being an international student in the US is navigating the complex process of visa sponsorship. I have been fortunate to have had tremendous support from my various international student offices, but even now I have trouble understanding the system. One of the reasons that obtaining a visa and maintaining status is so challenging is that there are so few international students to begin with—and therefore few mentors who can provide us with meaningful guidance.

These are some things I wish I knew as an international student in the US applying for residency. I applied in general surgery, so the details may be different in other specialties. This is not legal advice and does not represent the official policies or views of the institutions I have been a part of. Rather, they are things I have learned through my research or from the generous advice I’ve received from mentors over the years.

• Plan Early
  • Matching into residency is competitive, especially if you are limited to programs that accept international students and sponsor specific visas. I met with my international student advisor during my first semester of medical school. There is a decent amount of information online, but visas are often specific to your circumstances and country of origin. Ask your international advisor about Optional Practical Training (OPT, a practicum year that comes with most F1 student visas that you can use during your intern year) and transitioning to J1 vs H1b visas in residency. Get a sense of what barriers you might face and plan accordingly.
  • As early as possible, I created a list of all programs in the US that sponsored J1 and H1b visas for residency in general surgery. You can find this on places like Residency Explorer or the FREIDA AMA Residency and Fellowship Programs Database which make it easier to filter and search across the country. As you get closer to applying for residency, you should cross-check information from these aggregate sources with individual program websites because visa requirements change or have exceptions. I also took note of the applicant metrics of these programs (e.g., Step 2 score, publications, presentations) so I had a general sense of the bar I needed to reach to be considered a competitive applicant.
  • If you have specific visa preferences (e.g., H1b), several exceptions exist for US medical students. It can be challenging to figure out which rules do and don’t apply to you because international students at US medical schools do not go through the Educational Commission for Foreign Medical Graduates (ECFMG) but do require a visa to train in the US. I emailed program coordinators at places I was most interested in the summer before I applied to residency. I inquired about their visa rules and whether I would be eligible for a particular visa at their institution. Program coordinators are very knowledgeable and can be immensely helpful as they are often the ones putting together residents’ visa applications. If they cannot verify whether you would be a candidate for an H1b or J1 visa, I would request to be connected to the graduate medical education (GME) visa office.
• Identify Mentors
  • This is more challenging because visa information is personal. In the process of connecting with research mentors and academic advisors at my home institution, I proactively sought out individuals who could give me meaningful visa advice. My mentors and letter writers made introductions to their friends from residency, fellowship, or the conference circuit who were previously in similar situations to mine. I found these connections were most helpful for figuring out which questions I should or shouldn’t ask during interviews, which institutions had the broadest visa support, how to curate the list of programs I would apply to, and how to ultimately create my rank list. 
  • Joining organizations like F1 Doctors can also be helpful. I served as a mentor for this organization and, through this network, connected with other US medical students who were on a visa. Having peers who you can ask informal questions to can be reassuring and it is a bonus if you get to know them more closely on the interview trail. You may even become co-residents with some of them!
  • Touch base with your international student advisors. I cannot emphasize this enough. They are the most knowledgeable about the specific visa regulations and processes for ensuring you can get to the next step. Double-check what paperwork you need to prepare (e.g. H1b visas typically require that you have already completed Step 3 to be eligible), and then double-check again!
• Visa Specifics
  • J1 visa
    • This visa is for “exchange visitors” who are approved to enter the US for purposes of training, teaching, studying, and obtaining other skills, which includes graduate medical education. 
    • This is the most commonly sponsored visa for residency and fellowship.
    • The J1 visa is typically sponsored by ECFMG, even if you are not an international medical graduate who goes through ECFMG for the residency application process. 
    • The J1 visa has a 2-year home-country physical presence requirement which mandates you to leave the US after your residency or fellowship for a minimum of 2 years. This is a US law. There is a waiver for this home-country requirement (e.g., facing persecution in your home country, working in a federally underserved area in the US); however, this typically requires working with a lawyer, and obtaining a waiver is not guaranteed.
    • Depending on your country of origin, you will have to return to your home country and renew your J1 visa periodically. This can be challenging with a resident’s schedule and requires coordination with the person managing trainee schedules.
  • H1b visa
    • This visa is for “specialty occupations” and can be used to support trainees during residency and fellowship.
    • The H1b visa is more costly for residency programs and is often processed by the hospital system. The applicant cannot pay for the cost of sponsoring an H1b visa and this typically comes from the Department of Surgery (or the specific department you are applying in). Some medical schools have specific rules against sponsoring H1b visas, though rarely, exceptions may be made at the leadership level.
    • H1b eligibility typically requires passing Step 3 for international medical graduates but may not be required for a transfer from OPT (i.e., prior F1 visa). 
    • There is no 2-year home-country physical presence requirement for H1b visas; however, there is a maximum of 6 years for being sponsored on an H1b. If you are eligible for OPT, this means you can receive a maximum of 7 years. Be mindful of research requirements for your residency program to ensure you can complete all duties within the allotted time of your H1b visa. 
    • Paths to permanent residency (i.e., green card) are typically easier from an H1b visa than a J1 visa. This still requires working closely with a lawyer and may take several years. 

The residency application process is challenging and thinking about visas on top of everything else is difficult. I have found immense comfort in speaking with current residents who successfully navigated the visa process and in connecting with mentors who have advocated for me and generously shared their experiences. Working through the visa process in college, medical school, and residency applications has also made me reflect on my goals and refine them regularly. Where do you see yourself in 10-20 years? What do you want your life to look like? Where do you want to be?  If you can answer these questions, then you’re off to a good start.

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Yoshiko Iwai, MS, MFA, is a fourth-year medical student at the University of North Carolina at Chapel Hill School of Medicine. She received her undergraduate degrees from the University Michigan in dance and neuroscience. She subsequently received a master’s in science in Narrative Medicine and a master’s in fine arts in Creative Nonfiction from Columbia University in New York. She will be starting her general surgery residency at Massachusetts General Hospital in the summer 2024. Her research interests include surgical oncology, health equity, and medical education.