Coming to (and staying in) America

For citizens of other countries, the road to a residency in the United States is full of jargon, applications, lawyers and anxiety. Nevertheless, opportunities abound, and the welcome mat is out.

By By Lester Picker | Fall 2010 | Feature Articles

 

Latha Achanta, M.D.

"As I was nearing the end of my residency, I looked for a place that would continue my H-1B and would be willing to sponsor my green card. I was fortunate to secure a position at the University of Arkansas for Medical Sciences." - Latha Achanta

For Latha Achanta, M.D., it was a tense time fueled by the anxiety that one mistake could threaten her future as a physician. Fresh off a master’s degree in public health from the University of Texas, Achanta was in the United States on an F-1 student visa at the time. A native of India, she was applying for her H-1B visa to train in a United States hospital in internal medicine.

“Initially, the process was anxiety-producing,” says the 29-year-old Achanta, who recently completed her third year of residency at Abington Memorial Hospital in Pennsylvania.

The United States allows International Medical Graduates (IMGs), also known as Foreign Medical Graduates (FMGs), the opportunity to train in American medical institutions, as long as they meet minimum entrance requirements. Due to the undersupply of graduates from American medical schools, especially ones willing to go into family practice or internal medicine, this arrangement has historically benefited both the foreign physician and the hospitals.

Should you do J-1 or H-1B?
Two types of visas are offered to IMGs: the J-1 and the H-1B.

Most IMGs prefer the H-1B visa. The reason is simple: Those arriving on J-1 visas have up to seven years to complete their training. But after that time period, they must return to their home countries for at least two years or else file for what is known as a J-1 waiver.

The J-1 waiver has a major restriction that makes it less than desirable for many foreign physicians. To qualify, the recipient must serve for at least three years in a U.S. Medically Underserved Area (MUA), a Health Professional Shortage Area (HPSA), or a Medically Underserved Population (MUP). This alone might not be a significant barrier, but openings might not be available in their practice specialties or preferred geographic areas.

The H-1B has no such return provision and can be renewed, but it is considerably harder to obtain, says Robert Lubin, an immigration attorney for more than 25 years and founder of Robert Lubin & Associates in Herndon, Va. “For one thing, the H-1B requires that the IMG first pass the United States Medical Licensing Exam,” Lubin points out.

Muhammad Balouch, M.D., a 32-year-old internal medicine resident at Mount Sinai School of Medicine’s Veterans Affairs Medical Center in the Bronx, N.Y., chose the H-1B route. “You avoid having to go back home or getting an exemption,” says Balouch. “The H-1B is the quicker route to a green card.”

The IMG journey
In all cases, the process begins with an application to the Educational Commission for Foreign Medical Graduates (ECFMG), a United States organization that oversees the process of certifying the credentials of IMGs for entry into U.S. residency training. All IMGs, regardless of citizenship, must be ECFMG Certified in order to begin U.S. residency training.

IMGs, like graduates of U.S. programs, use the Electronic Residency Application Service (ERAS) to submit application materials to U.S. training programs. Competition for U.S. residency slots is highly competitive and a substantial hurdle for many IMGs.

 

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Moonlighting 101

Though opportunities to moonlight are on the upswing, fewer residents and young doctors are taking advantage of them, creating a messy void. Residents who do moonlight, however, can significantly boost their income and lessen the financial strains nearly all face.

By By Marcia Layton Turner | Fall 2010 | Feature Articles

 

Brett Yockey, M.D.

Brett Yockey, M.D., moonlights at a rural hospital in addition to his residency rotations. Both the extra money and extra responsibility that moonlighting can provide can be beneficial to young physicians.

Two weekends a month, Brett Yockey, M.D., a third-year radiology resident at Indiana University in Indianapolis, gets in his car and drives two hours south to run the emergency room at a rural hospital.

Although he earns $4,000 a month as a resident, one 12-hour shift at the community hospital generates an additional $1,260—$105 per hour. And with a wife, two children, and $170,000 in student loans, that extra money isn’t just nice—it’s necessary.

Yockey isn’t the only doctor to tack additional shifts onto his already busy residency rotations. In fact, other residents from his program make the same two-hour trek to that hospital, although not all residents at Indiana University are permitted to moonlight.

Emergency residents, for example, are prohibited from performing any additional medical services outside their residency, which may be why the need for emergency room help existed in the first place at the community hospital.

Leon Aussprung, M.D., J.D., LLM, moonlighted during his residency at Thomas Jefferson University Hospital in Philadelphia and later as an attending physician while enrolled in law school. Aussprung often picked up extra shifts generally filled by residents. There simply weren’t enough residents to meet the hospital’s need for coverage, he explains, and his pediatric residency program permitted moonlighting. So he worked a few night shifts at Thomas Jefferson and other hospitals in the Christiana Care system.

To qualify for these additional shifts, Yockey and Aussprung had to hold a permanent license, which involves completing the first year of residency and passing a “Step 3” licensing exam. With that, Yockey was permitted to stand in for emergency room physicians on weekend shifts, and Aussprung often manned the neonatal intensive care unit (NICU).

Not all moonlighting opportunities require a permanent license, however. As a second-year family practice resident at Boston University (BU), Michael Noonan, D.O., discovered he was eligible to moonlight at the residency facility where he was based as long as he was already doing rotations there. To work anywhere outside BU’s hospital system, however, he needed an unrestricted, or permanent, license.

Finding work
So Noonan began exploring moonlighting opportunities to make some extra cash, and discovered fairly quickly that he could pick up extra shifts in admissions at his hospital. From the middle of his second year of residency to the end of his third year, he admitted patients to the hospital and assisted in morning rounds.

He would work 12- to 14-hour shifts, generally 7 a.m. to 7 p.m. on Saturdays and Sundays, one to three times a month. In exchange, he earned $75 per hour, or about $2,700 for those three shifts, which, he points out, “was about what I  was making after taxes as a resident.” That additional cash “can be a huge differential for a person in residency,” he says.

Aussprung also started his search for moonlighting work internally and had no trouble finding it. His residency director routinely alerted the residents in his program to moonlighting opportunities—shifts that needed filling within the hospital—and he pursued it. He could make about $1,000 working a 24-hour weekend shift, and frequently did.

Yockey contacted headhunters in the Indianapolis area to find his moonlighting gig, who inquired about openings he might be qualified to fill. Most hospitals wanted a board-certified physician, he reports, which he wasn’t. But one headhunter had a hospital willing to accept a doctor without those credentials. He got the job.

Noonan reports that physician staffing groups frequently have part-time work appropriate for residents and are a popular place for residents to begin their search. Although he did not approach them about moonlighting opportunities, placement services such as these are a smart starting point.

 

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Shedding light on your moonlighting contract

Before you accept any moonlighting opportunity, make sure you take into account these contract considerations.

By By Bruce D. Armon | Fall 2010 | Legal Matters

 

The economy is still uncertain, and physicians are not immune to these challenging times. You might be tempted to create your own stimulus package by moonlighting.

Moonlighting usually refers to a resident or fellow taking a second, part-time, clinical job. In most cases, the reason for taking the second job is solely economic: to earn more money to supplement your salary.

The moonlighting contract protects you and the party for

whom you are working.

Moonlighting is, however, no longer the exclusive domain of residents and fellows. In an era of decreasing reimbursements from third-party payers, physicians with varying years of professional experiences and specialties are attracted to the opportunity to earn extra dollars by engaging in extracurricular clinical engagements.

Whether you are a resident, fellow, junior attending or seasoned physician, there are important legal considerations you must address before executing a contract to be a moonlighter. And yes, you should execute a contract. Do not rely upon a handshake or an exchange of e-mails. The moonlighting contract protects you and the party for whom you are working. It also helps prevent amnesia when there is a disagreement or misunderstanding between you and your second employer regarding your respective rights and responsibilities.

Are you allowed to moonlight?

This is the threshold issue that must be addressed before you do any clinical (and, depending on your contract, non-clinical) activities for any other party besides your primary employer.

Imagine language in your contract with your primary employer that states: “During the term of physician’s relationship with employer, physician shall not engage in any activity that is competitive with employer unless physician receives the advance written permission of employer, and such approval may be revoked at any time.”

There are several questions that must be addressed:

  • What is a “competitive” activity? Is it clinical? Is it nonclinical, such as being an expert witness or dealing with intellectual property?
  • Is it tied to the radius of the contract’s restrictive covenant provision?
  • Is it tied to the hospital(s) or other ambulatory facilities where your employer’s physicians have privileges?
  • Is it limited to a particular specialty or a particular set of procedures, such as cosmetic, or cash pay versus third-party payer reimbursements?

Before you can safely take advantage of any moonlighting opportunity, you must get these issues addressed. To be sure you are not going to violate your primary employer’s contract, you should get these answers in writing, and have the same signed by you and your employer.

What is your limit?

There are some people, including physicians, who require very little sleep to function at an optimal level. However, your contract with your primary employer may not address your minimal sleep habits and needs and may simply state: “Physician shall devote his/her full time and attention to employer.”

What constitutes full time? Part of the answer may be dictated by your “normal” working hours. It may be unacceptable to work from 7 p.m. to midnight after working for your primary employer earlier in the day or having regular hours the following day. Is it OK to work a weekend shift for another employer when you have no regular office hours that day or on-call responsibilities?

 

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Martinsburg—Where history meets vitality

Martinsburg, W.Va., is swimming in history. And a renaissance in the economy, its hometown atmosphere, and nearness to the Washington area is making it a more and more appealing place to live.

By By Eileen Lockwood | Fall 2010 | Live & Practice

 

Job selection seldom hinges on only one factor, but for Thomas Withuhn, M.D., drive time to work was a biggie—especially after several years of enduring

General Adam Stephen House

The General Adam Stephen House was built in 1774 and is open to the public.

heavy traffic in medical school, internship and residency in Los Angeles and Washington, D.C.

So he went in search of the ideal job combined with minimal strain on the gas tank.

“During my residency, I had an opportunity to work in a smaller community hospital in Pasadena, and I really liked how much neater it ran with 150 beds, so I started seeking out all the similar opportunities within three hours of D.C., and narrowed it down to my two favorites: Salisbury, Md., and Martinsburg,” he says. “They’re both beautiful little towns, but I didn’t want to negotiate the Chesapeake Bay Bridge” during frequent visits from Salisbury to friends and family in the D.C. area, he says.

Withuhn’s Valhalla turned out to be the historic municipality of Martinsburg, located in Berkeley County on the dangling Eastern Panhandle of West Virginia, mostly bordered by the Potomac and Shenandoah rivers.

“It met everything I was looking for,” he explains. A serendipity was the fact that his wife is an alumna of Shepherd University in Shepherdstown, about 10 miles from their new home. City Hospital, where he works as a hospitalist, is licensed for 260 beds but currently staffs 140 to 160.

Among the most appealing aspects of this smaller hospital, Withuhn says, is that “you have a smaller group of people within which to work, and they know each other better. My (patients’) length of stay is much shorter because I can get things done faster. (For instance) it’s nice to get MRIs the same day or the next morning.”

These days, he describes his home-to-work drive as “very short.” In fact, he gloats that if it weren’t for recreational road trips, “I’d have to fill my gas tank only twice a year.” more »

 

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Check your ego and let trust flow

Tell the truth in every situation, and you’ll build a culture of trust among physicians, nurses, administration and patients.

By By Brian Jones | Fall 2010 | Remarks

 

As a business consultant, speaker and trainer to hospitals, physician practices and others, I have been hearing a lot about trust recently.

Some might dismiss trust as a “touchy-feely” concept, but I have spoken to many hospital CEOs, CMOs and physician practice leaders who trace many of their challenges to a lack of trust.

This lack of trust can be between management and staff, between physicians and nurses, between physicians themselves, and even between members of management.

And we are not doing a very good job of hiding our lack of trust from our work forces and colleagues.

In fact, in one recent study by the American Nurses Association (ANA), about half of nurses say that they would not be comfortable having a loved one receive care where they work.

The study concludes that these nurses have lost trust in their employer—so much so that they wouldn’t want their child or parent to be cared for in their facilities. There’s a business case to be made for rebuilding this kind of trust, because word-of-mouth marketing, especially from employees, is the most valuable type of marketing for a healthcare facility.

Before we go any further, let’s define what trust means. Trust is the ability to be vulnerable and fully present and real in all interactions.

Trust is usually better defined by what it is not: politics, meetings after the meeting, defensiveness, and ego-driven decision-making. My experience in health care tells me we have a ways to go when it comes to driving these destructive traits out of our hospitals, practices and offices.

What can be done to retain or restore trust in a healthcare workplace? In our book, Ordinary Greatness, my co-author Pam Bilbrey and I examined this question, and here is what we found.

Tell the truth

Sounds simple, but most employees we interviewed as we researched Ordinary Greatness who had lost trust in their boss could tell some story about a time they felt they were lied to, spun, or were told less than the unvarnished truth.

The boss often has a different perspective when confronted about this disconnect, and blames “the script HR gave me,” the employee’s unrealistic expectations, or the economy.

Physicians who are not aware of some of their blind

spots will not be likely to inspire trust.


But is there ever a reason not to tell the whole truth? Our commitment to protect confidentialities aside, be sure you are telling the truth in every situation.

A friend of ours asks his young children every night when he tucks them in, “Did Daddy tell the truth to you today?” We asked him why he did this. He said, “Because I want to avoid situations where my kids think I lied to them when in reality we just had a misunderstanding. For example, if my kids ask me if I could take them to the park, I might say yes, thinking I will do it this weekend, when they were thinking of today. I want to catch that stuff as it happens.”

 

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Robots can extend a physician’s reach and expertise

Through advances in telemedicine, in-demand specialists can reach those in need without having to transport the patient—or the physician—to other facilities.

By By David Geer | Fall 2010 | Tech Notes

 

Today, telemedicine enables physicians to extend their presence and reach to multiple locations in the form of robots that see, hear, speak and interact with patients and staff.

InTouch Health has the only FDA-cleared remote presence (RP) products on the market, such as the RP-7i (and predecessor RP-7), which connect directly to Class II medical devices including electronic stethoscopes, otoscopes and ultrasound. This enables physicians to diagnose and consult with patients from a distance.

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Thanks to the robotic technology, specialists in demand for stroke, ICU care and pediatrics reach patients they otherwise might not. Burn victims, heart patients, psychiatric patients and trauma patients benefit as well.

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Robot

To accomplish examinations and consultations, the robot's head pans and tilts, giving the doctor a complete view of his surroundings. The robot's camera, monitor/display, microphone and speaker extend the doctor's natural senses while ensuring that the doctor is seen and heard, as well.

For example, the Brooke Army Medical Center Burn ICU employs the robots to assess burn victims from as far away as Baghdad, says Jennifer Neisse, marketing communications manager for InTouch Health, headquartered in Santa Barbara, Calif. The robot’s camera zooms in from multiple angles on skin sections affected with burns for accurate, immediate examination.

Cardiologists facilitate distant monthly cardiology and echocardiogram consults through the robots. Remote hospital staff plug ultrasound devices directly into the robot’s video ports for the cardiologist’s use. Trauma units use the robots to make up for the shortage of trauma doctors. And psychiatrists reach out to rural areas through the robots, providing consultations.

PracticeLink spoke with three physicians specializing in neurology and pediatrics who have made extensive use of RP robots.

Neurologist offers urgent care robotically

Dr. Paul M. Vespa, M.D., director of the Neurocritical Care Program at UCLA Medical Center in Los Angeles, has relied on the RP-7 and now the RP-7i remote presence robots for a total of more than five years. Vespa uses the robots in the neuro ICU as he visits, diagnoses and treats neurosurgical and stroke patients.

Via the RP-7i model, Vespa speeds down clinic and hospital hallways at the patient’s side as staff transport them on gurneys.

Three balls in the robot’s base, each one six inches in diameter, enable this precise locomotion. Motors drive the balls, which also spin passively when following another ball’s lead. The robots maneuver accurately in tight spaces without bumping into walls or people.

In the big picture, the robots help Vespa address the shortage of ICU practitioners available to physically enter the ICU. When needed, Vespa drives the RP-7i model robots into the neuro ICU to offer immediate care to critical stroke victims.

To accomplish examinations and consultations, the robot’s head pans and tilts, giving the doctor a complete view of his surroundings. The robot’s camera, monitor/display, microphone and speaker extend the doctor’s natural senses while ensuring that the doctor is seen and heard, as well. The robot’s audio capabilities enable the physician to tune in to specific sounds or conversations, as if he were in the room himself.

The RP-7i brings Vespa up close to observe and monitor patient response to medicines and treatments in real time. “Rather than ordering a medicine and coming back the next day to see whether it worked, I can see that right away,” he says.

This saves time for the patients, speeds care as the doctor shifts treatment to another medicine more quickly, and even changes outcomes. “By moving more quickly to an approach that works, we can save the patient’s life,” Vespa says.

 

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Will work for travel

Looking for a unique experience? International intrigue? Consider locum tenens opportunities both home and abroad.

By By Karen Edwards | Fall 2010 | Feature Articles

 

David Rideout, MD

During their stay in New Zealand, David Rideout, M.D., and his family visited many of the sites from the “Lord of the Rings” trilogy—including Mt. Sunday, pictured here. Although a gigantic castle had been built on this mountain for the filming, Rideout says there is no longer any trace of it.

There are plenty of reasons physicians pack their bags and head overseas to practice medicine. Some have charity at heart, rushing to aid the earthquake victims of Haiti, for example, or to Third World countries where doctors and modern medicine are desperately needed. Others are seeking thrills or experience on a locum tenens basis, an opportunity to travel and work in other locations or with people from other cultures.

Many physicians looking for a chance to practice in an international environment generally head for one of two locations: Australia or New Zealand. Both countries welcome American-trained physicians, and both offer a rich, culturally diverse environment with a common language and a familiar healthcare system.

That’s not to say other practice opportunities don’t exist, however. Amy Griffin, director of the international division of recruiting firm VISTA Staffing Solutions, currently places physicians in Bermuda, Canada, New Zealand and Australia, with plans for expansion.

Recently, the United Arab Emirates—especially Dubai and Abu Dhabi—also has opened its doors to American physicians. There, new hospitals are being built at a rapid pace, says Steve Frank, a senior search consultant for the Missouri-based recruiting firm Enterprise Medical Services. “Some adventurous American physicians decide to go there, looking for a challenge,” he says. For the most part, though, physicians immigrating to the Middle East are originally from that part of the world and are heading back to be close to family.

In New Zealand, however, International Medical Graduates (IMGs for short) are increasingly becoming the norm. Ian Powell, executive director of the Association of Salaried Medical Specialists, recently told a reporter on New Zealand’s TV One that more than 40 percent of New Zealand’s specialist physicians are IMGs. more »

 

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