In our Season 4 finale wrapping up 2024, Febrile is excited to host our biggest guest list yet to discuss the importance of International Medical Graduates (IMGs) in infectious diseases! 

Our guests:

Ana Del Valle (Pediatric ID faculty at Arkansas Children’s Hospital)

Cristina Tomatis (Pediatric ID faculty at Nationwide Children’s Hospital)

Diego Cruz (Current pediatric resident and recent graduate of pediatric ID fellowship program at Nationwide Children’s Hospital)

Radhika Sheth (Adult ID faculty at Henry Ford Health System)

Shweta Anjan (Adult ID faculty at University of Miami and Jackson Memorial Hospital)

Zheyi Teoh (Pediatric ID faculty at Seattle Children’s Hospital)

Cesar Berto (Adult ID faculty at University of Alabama Birmingham)

Episodes | Consult Notes | Subscribe | Twitter | Merch | febrilepodcast@gmail.com

Febrile is produced with support from the Infectious Diseases Society of America (IDSA)

Hi everyone, welcome to Febrile, a cultured podcast about all things infectious disease.

I'm Sara Dong, your host and a Med-Peds ID doc.

I do know we've been on a bit of a short break, people have probably noticed we haven't had new episodes.

I do have things in the pipeline that are coming up for 2025.

Today, we have several guests and I told them that we're breaking a Febrile record because I don't think I've ever quite had so many folks on.

So I'm really grateful that you guys are here and looking forward to hearing more about your perspectives.

And so I'm going to start by having everyone go around, say hello, tell you a little bit about themselves, and then we'll jump into today's topic.

Ana Del Valle: Hi, I'm Ana Del Valle.

I'm originally from Monterrey, Mexico, where I completed medical school.

Then I moved to the U.

S.

to pursue residency and fellowship in Pediatric Infectious Disease.

I am currently an Assistant Professor of Pediatric Infectious Disease at Arkansas Children's Hospital, and that is where I am currently J1 visa waiver.

Hi, I am Cristina Tomatis.

I'm from Peru, uh, where I went to med school, but then I did residency in Spain, in Madrid, and then I came here for fellowship to Nationwide Children's in Columbus, Ohio, and stayed since, but I had to redo residency for two years.

And, and then now I'm an assistant professor in ID here.

Hi, I'm Diego Cruz Vidal, I'm a current pediatric resident, but I'm originally from Colombia where I did med school and pediatric residency for the first time, came to the U.

S.

to do pediatric ID fellowship at Nationwide Children's Hospital, and then stay at the same institution to complete a two year residency to be able to be board eligible similarly to Cristina.

Hi everyone, my name is Radhika Sheth, I am an adult infectious disease physician with the Henry Ford Health System in Michigan.

I did my residency at the same place and I did my infectious disease fellowship with Oregon Health and Science University in Portland, Oregon.

I'm originally from India, which is where I did my med school and I'm currently also working with the residency program and involved in medical education.

Hey, hi, everyone.

I'm Shweta Anjan.

I'm a adult Transplant Infectious Disease Physician at University of Miami at Jackson Memorial Hospital.

I'm also the Program Director for the TID Fellowship.

I'm the new Program Director to start in July, so it's a big learning curve.

I actually started my career as a visiting medical student, and my first elective was in infectious diseases, so that's where I started.

I completed medical school from India and moved to the U.

S.

in 2012 for residency.

Hey everyone, I'm Zheyi Teoh.

I go by Teoh, my last name.

I'm a pediatric ID doctor here at Seattle Children's.

I was a Med-Peds resident in Louisville and then a fellow at Cincinnati Children's.

Um, and I'm originally from Malaysia, but actually got a J 1 persecution waiver before coming to Seattle, so I'm excited to be here.

Hi everyone, my name is Cesar Berto.

I'm originally from Lima, Peru.

Um, I'm a, right now, a transplant I.

D.

adult doctor at the University of Alabama where I'm completing my waiver, my J1 waiver as well.

Awesome.

I'm so excited.

This is really fun for me because I have some old friends on the call that I met in residency and the folks I've met along the way through Febrile and other things.

So, um, again, just like super excited that you guys are here.

And this episode marks the end of our, what I call our seasons, but the end of 2024.

It is reaching our fourth anniversary of Febrile, which still seems a little bit crazy to say.

And so I always take a second just to express gratitude to anyone who either has volunteered their time to create educational content for the show.

And then really anyone who has listened, supported, or shared Febrile with learners and, and others in ID, um, the platform has continued to grow.

We've had over 640, 000 downloads, um, and those have really been from all over the world.

And, uh, the other big change for this year is that we are now sponsored by the IDSA, which has helped a lot.

I was very excited because this year we launched something that I call the StAR episodes, State of the Art Review, that highlights key topics in ID and pairs with these CID publications that have been coming out and are excellent.

So we have more of those coming to you in the next year as well.

Today, we're going to talk a little bit about the U.

S.

ID Fellowship update on Match, which is similar to the last two years, and then this time I want our conversation to focus a little bit on international medical graduates and their experiences and kind of putting that in the context of Match a little bit, but also just kind of speaking generally and sharing awareness.

And so if people do want to listen to the prior season episodes for the end of the year, there was episode 65, which we focus a little bit more on sort of history and some of the challenges of growing our ID workforce that focuses a little bit more towards the adult side.

And then last year in episode 89, we talked a little bit more about the pediatric perspective, but I can't forget our culture section.

So we have to have everyone share a little piece of culture that they have enjoyed recently.

This can be just something fun or it can be sort of your end of 2024 pick.

That's totally fine as well.

Ana Del Valle: I love listening to podcasts in my way to work or sometimes even when I'm working and doing notes.

And recently, Uh, one of my, actually one of my fellows from, co fellows from fellowship, recommended a podcast called Normal Gossip.

So if you really want to like shut your brain down and just don't think about it and listen to funny stories from, you know, some other normal people and laugh for a while, I would highly recommend.

Just noting that down.

You said no more gossip, no more gossip?

Ana Del Valle: Normal gossip.

Normal gossip.

Okay, um, okay, now it's my turn.

I really like musicals and I'm trying to get my kids into the same, into the same addiction.

And so recently I just found out through Facebook that they had a Dog Man musical, which is a book for kids, for the adults that don't know about it, um, which was very nice.

And we went, it's the first time of me going to the Southern Theater in Ohio.

Which, and I learned that it's one of the oldest in Ohio from the late 1800s.

And you know, a lot of famous people have been there.

It was very nice.

A small, very small, but nice.

It was like a time capsule.

It's very pretty.

So I recommend.

For me, this year has been, I enjoy reading a lot, especially, uh, reading, uh, fiction, and I enjoy very much in a fantasy and sci fi kind of stuff.

Eh, I learned that the Wheel of Time is a series of books because of the Amazon Prime TV show.

The first season is kind of bland, so don't necessarily strongly recommend it in the TV show.

But then I said, this premise is fine.

Let's start reading the books.

And I read the first one and it was great, but then I'm stuck because the total series is 14 books and I'm in the number nine.

I'm trying to power through at this point, uh, highly recommended.

But if you are someone that needs to finish what you begin, uh, just, you need to know what you're getting into.

I'll actually piggyback off of Diego's comments.

Uh, I am, have also recently been on a sci fi kick and I read a book called Children of Time by Adrian Tchaikovsky and if there's anybody who loves sci fi, this is probably one of the best books I've read in the last decade.

It is a fantastic book.

Um, so I highly, highly recommend that.

I think this past year for me, culture wise, I think was a trip to Istanbul, actually, for a conference.

And I got, I got to enjoy some of the local food, and I must say, I'm a big fan of Turkish coffee at this point.

I'm gonna go a different route, and I've always been an avid skier, um, and now that I'm new to Seattle, I've gotten to explore a little bit of backcountry skiing, which is a very different activity, but it has helped change my relationship with winter a little bit,

doing so much skiing and backcountry skiing, and I actually look forward to the winter, um, because it does get very dark and cold here.

The previous two times I was on the podcast, I mentioned musicals.

So I think I'm going to mention a musical again.

Uh, this year I watched The Notebook, which, um, uh, was a musical based on the movie, which actually was quite good.

And as you can imagine, I cried as I would do with the movie.

Unfortunately, it's now out of season, but, um, it was really good.

I didn't realize there was a musical for that.

Yeah, they do a musical for everything.

Yeah, that's true.

Awesome.

As fitting of our season end, I would like to share congratulations and welcome to all of our new incoming ID fellows.

So we have over 310 new adult ID physicians and over 40 incoming pediatric ID docs.

Overall, there was a slight increase in the number of matched individuals.

The percentages are pretty stable, um, from prior years as far as how many programs have filled.

But I think Shweta and Diego are going to give us just a little update on the breakdown of the match result stats, uh, for the appointment year 2025, so this coming year.

So I think it's been a great year for adult ID.

We have 179 programs, half of it 91 filled, which is great, and we'll be welcoming 360 new ID fellows next year, so that's a little bit of an increase from last year, and I'll take it.

I'm an optimist, and that's how I choose to look at these numbers.

On the pediatric side, we had a total of 59 programs and 25 of them filled all their positions and having a total of 43 new peds ID fellows upcoming for the next year, which in percentage is pretty similar to the last couple years, but it has been a total increase in numbers compared with the last two years of the match.

And I'll put the link to the official, uh, IDSA PIDS statement and links for folks who do want to look at the numbers in more, uh, in more detail on the consult notes, but you can also find them available online.

Actually, I was just going to point out how Uh, 20 percent of the adult ID applicants were foreign and 16 percent of the pediatric applicants were foreign.

So we are a pretty sizable proportion of incoming fellows.

So I think that's why, you know, then we're so grateful to be here to talk to you because we feel like we're a big constituent.

And so hopefully have a big voice.

Absolutely.

Wow, you gave me a perfect transition.

What I am hoping that I will establish, obviously it's only been a couple years, is that these season finales just try to take different perspectives and talking about the workforce.

And I mentioned kind of what we've done the prior two years before.

I think a lot of the themes overlap regardless of what population someone might be talking about, like early exposure to ID is helpful, the importance of finding mentorship.

Um, and then of course, for us to talk about what are the roadblocks and barriers that we need to work on to expand our ID family.

And so today I've invited all of you guys here to share perspectives on the international medical graduate experience, both of yourselves and just kind of talking more generally for those who are less familiar.

And we are really lucky because we have a mixture of adult and pediatric docs here.

And I think everyone heard a little bit of snippet that you guys have a variety of different career paths that you've taken, and so hopefully we'll hear a little bit more about that as we, um, kind of talk about those.

First, for those who do not immediately know what IMG stands for, I wanted us to define that so that we're all on the sort of same page to start off with.

So, Cristina, could you tell us a little bit about what that means?

Yes, so international medical graduate is somebody who has done medical school abroad outside U.

S.

or Canada, and you might be a U.

S.

citizen or not, um, or from another country and did school there.

And an IMG, which is the acronym for it, can apply for a fellowship, may have completed an ACGME accredited residency or not, uh, or equivalent abroad.

IMGs constitute 25 percent of the workforce in terms of just doctors in general in the U.

S., so that's a quarter of the workforce being international graduates.

Um, and when we're talking about ID in specifics, then, um, like Teoh already mentioned, IMGs are a sizable chunk of the ID candidate pool, um, and actually, Dr.

Vera Luther just came out with her match analysis.

And this year, the number of US MDs actually decreased, uh, from last year in terms of candidates, and the number of IMG candidates actually increased, so there is, uh, a pool of candidates that we can definitely tap into for strengthening the ID workforce, and I think that deserves a special mention

and so I, I guess I should say my perspective is that I am not an IMG, so that's why I'm glad to be hearing from you guys.

I will say though, that through training I've had, you know, conversations or attended sessions where those who are international medical grads have really shared struggles that they've had either finding guidance or, um, you know, mentorship or, or resources.

And I think in particular, that tends to come up when we start talking about job searches and that search and trying to find folks that might even be a component of their experience with their own program leadership.

And so I thought it would be helpful to provide listeners with a better understanding of what are some of those things that folks are struggling with and what they're encountering in their experience, um, in U.S.

training system.

So if we could maybe talk about that, what is the landscape of training on a visa?

You know, what does that look like in the context of ID fellowship training?

Um, and, and other things that you think have been limitations, um, from that experience.

For someone that requires a visa to train here in the United States, they are usually on two types of visa, which can be a J 1 or an H 1.

Those are the two most common types of visa, and the main difference is that the J 1 visa is exclusively a training visa.

So you compromise yourself that at the end of your training, you will return to your home country to practice back at home.

But if after doing your training, you get used to the U.

S.

system and you want to continue practicing here, You will need to waive that promise that you made, and that is the easy explanation of the waiver.

Now, there are many pathways for how to do the waiver.

The H 1 is a little bit more straightforward.

It's a work visa.

It's a little bit more expensive for the program where you will do your residency or your fellowship, but it has the advantage of having a much more smoother process to transition into a green card, which would allow you to work here.

Um, usually the H 1 visa, it's a little bit more restrictive in terms of the, um, places where you could apply for fellowship.

And that is one of the, uh, important caveats of this.

Having said that, I know that more and more programs, especially in ID, are trying to cover this as to, you know, increase the opportunities to increase the workforce in the U.

S.

And, um, now I'm going to pass to talk about, like, the waiver processes, um, after the J 1.

Ana Del Valle: So the waiver process is pretty complex, um, sometimes it kind of feels like you have to become an immigration lawyer yourself to try to understand these processes, um, I don't think I've ever read so much law in my life, and I hope I don't have to do it again, as when I was going into the process of trying to figure out how to get a job.

So we won't go into a lot of specifics into what each pathway means, and there are some that are more common for J1 visas than others, and more people are going to pursue because they're easier than others.

So, I think the one that we're all familiar with, that most people will at least try to pursue, is the Conrad 30.

Um, this, an important thing to know, is that this one is going to vary state by state, right?

So one thing when you're looking for a job, and you know that you're looking for a J 1 visa waiver job, my advice would be if you have states in mind where you want to practice, that is the place to start.

You go and you look at the specific requirements for that state, for the Conrad 30, and the 30 means that there's 30 visas available per state, right?

So we start thinking about how challenging this can be, right?

There's 30 positions available for state, for a state, for all visa applications.

So, it does not matter if you're an ID physician, if you're a hem-onc physician, if you're looking for a surgery waiver, there's only 30 available positions through that pathway.

A lot of specialty physicians that are looking for a subspecialty waiver will go through this pathway, but it's very important to keep in mind that you have to look at the specific requirements by state, because some states will prioritize by type of specialty, some will prioritize by primary care.

And for you to be able to see if you qualify for this waiver, the hospital where you're going to practice or the private practice that you're going to pursue has to be in what they call an underserved area.

So, you first start with the state and then you see what hospitals are there, and then you have to look up the state in a specific website to see if they're qualify as under underserved, so, so that's kind of like the primary pathway that a lot of people pursue.

That is what I did, and that's what the type of waiver that I'm, I'm doing.

There's some states that are easier than others because they're less competitive.

Then, you know, there's other types of waivers that for subspecialty don't really apply, right?

They're the HHS waiver, but that's only for primary care.

There's an Appalachian Regional Commission, um, the Delta Regional Authority, and all of them are going to have different type of requirements and specific things that you have to meet to be able to pursue that path, uh, that waiver path.

And there's also, you know, what's called a hardship waiver that it has its own requirements and that you also have to be aware of how long it takes for you to be able to get it, to be able to apply with enough time for you to be able to start working when you need to.

So that's a very, very general, um, kind of overview of different waiver pathways and you, as Sara mentioned, you can find more information in the website.

Um, but that's, that's a place to start.

And this is helpful to me because I knew the general concept of the number of spots and by state, but I actually had not heard the term Conrad 30 before looking at some resources as we were prepping for this.

I think because I had friends who explained the process and how it was so, um, individualized depending on where you wanted to go.

And I was going to say, you know, this is all complicated, but you know, do your research because this changes a lot.

You know, it's called Conrad 30, but there are bills trying to make it Conrad 35 or Conrad 40, and even within interested U.

S.

government agencies, I think a lot of people are probably familiar with the Appalachian and the Delta Region Authority, but they actually just created a new one called the Northern Border Regional Commission, which covers the New England and Eastern states, and that's brand new that probably most of us had not heard of.

And even within the persecution or hardship waiver, so I'm probably like a rare person who went through that pathway, um, and, um, you know, it is challenging and it is very time consuming, but to be honest, I wasn't even aware I was eligible through that pathway, and I had made a lot of assumptions that I wasn't until I spoke with an immigration lawyer, and I think they're,

at the end of the day, sometimes you're best friends, expensive friends, um, but they are very, very, really helpful resources, especially those that work with a lot of IMGs in medicine.

And these number of spots are not balanced as far as adult versus peds, right?

It's physicians in general, correct?

Okay.

There's lots of head nods for those who are listening.

I just wanted to add, and I don't think we mentioned, uh, you know, pre discussion is that, um, before, you know, even applying to come here and then decide to stay.

The way IMGs come, you have to be, uh, certificated in that, so your MD title is valid here.

So we go through the same steps as the same, the same exams as the same, as the US graduates, and then we get an, a foreign medical graduate certificate.

And that's run by the, um, you know, it's educational committee of foreign medical graduates, which is the ECFMG.

And then they have centralized the, the J 1 visa process.

So that's why it's much easier for all the programs to offer J 1 visa for all the applicants, but then it's, so it's, um, I think that's why there's, it's so much easier to come initially with a J and once you're with a J, you're stuck that you're going to need a waiver later, uh, if that happens versus, um, coming up with, for another, with another, uh, word visa.

I will just add a very quick point that most people don't know you can apply for different waiver mechanisms at the same time.

So you can do a Conrad 30 and a persecution at the exact same time.

And most people think you're stuck with one or the other.

Ana Del Valle: But also know the caveats, right?

Like if you apply for both, if you are pursuing a persecution way or a hardship waiver and you're applying for a Conrad 30 at the same time, and you get approved for the Conrad 30 first.

You have to take it.

You cannot say like, oh, well, you know, so that's where as, as you mentioned, you know, I would highly, highly recommend if you're going to pursue a persecution waiver, do get an immigration lawyer, because those are very complicated.

And at the end of the day, you can probably do certain things yourself, but it's going to be extremely time consuming and I think it's just going to increase your stress levels really a lot if you try to do it yourself.

So if you're going for a hardship or a persecution waiver, my advice would be really, really get a good immigration lawyer.

I would say get a good immigration lawyer

regardless.

Yeah, I just could add that when you are interviewing at different programs, many of the institutions that have waiver have an international office, and they have lawyers within them.

And then they also know, like, how successful they can be with Conrad 30 versus the other modalities.

So that can give you a good sense of, like, What would be your safe pathway when you get hired and say for x reasons your waiver doesn't get approved, what are your backup options that you may have in that institution?

Ana Del Valle: Yeah, absolutely.

I think You know, it cannot be said enough of how much it can be an advantage to have an institution that knows how to do a waiver.

It just makes the experience so much easier.

If they have a good international office and they have experience doing waivers, I would say definitely a green flag for that institution.

Um, because it also will save you the money of having to get your own immigration lawyer.

Right?

Um, so, so definitely when you're looking for jobs, one question to ask is, do you have an immigration office?

Right?

What does your immigration services look like at your institution?

And I will say just to mention to that point that it may happen that within that institution in the, in the division that you're applying to, they may not have the experience of doing a waiver, but the institution itself may have done it for other types of specialties or types of physician.

So it's a, I will say it's very, very important to like talk with our immigration office and say, what has been your experience with waivers and don't try to only rely in the response by the head of the division, because they might not be aware of all the processes that have gone through the institution in other divisions, different to I.

D.

I just wanted to mention, and this might be jumping slightly ahead, but just, just.

As we're talking about asking your prospective jobs, I also always tell residents who are applying to ID fellowship programs, etc., that when you're applying to programs, definitely ask the leadership how have they been able to support their IMG trainees, because sometimes that can be a big challenge when your faculty doesn't know how to offer these kinds of abilities for support.

Yeah.

And I think that's actually kind of a nice transition because the ending of this episode, we wanted to focus a little bit more on some of those challenges and sort of the different stakeholders involved.

And so I will share a recent publication from J PIDS that has several of our guests as authors overcoming challenges for non U.

S.

citizens.

IMG graduates and pediatric ID.

And I really liked how you had bucketed some of those, uh, both challenges and possible solutions by those stakeholders.

So the individual, uh, non U.

S.

IMG themselves, there's the fellowship program leadership and mentorship and colleagues, and then there's sort of moving out of your program to the division, the institution as a whole, and those leaders.

And then lastly, even bigger picture is what can our national societies do to support IMGs?

And I wanted to kind of walk through those and talk about them in a little bit more detail.

You've already started to mention a lot of the things that individuals are probably processing as they're either anticipating ID fellowship or now they've completed fellowship and they're looking for a job.

Are there other things that you guys want to mention as far as what individuals are having to think about as far as this timeline that you're mentioning, thinking about the job search and other pieces?.

I think Ana already mentioned that, you know, if you're somebody who's on a J 1 visa and a trainee looking for a job, start your search early.

And I would definitely try and organize your search around, already has been mentioned, what states you're trying to target, to practice.

Um, and, definitely get some support from faculty members, either within or outside of your institution, who've had experience doing this, um, because, you know, it's a very time sensitive process, um, most people usually have a job lined up even before they're finishing first

year, which has, you know, its own challenges, um, but because the paperwork takes so long, make sure you have everything ready on time.

Ana Del Valle: Yeah, I would say, don't wait, right, for your program director or for someone else to come and kind of ask you, Hey, how are you doing with your job search?

Be very proactive.

You know, for peds ID, start looking for jobs at the beginning of your second year, towards the middle of your second year, just start getting things lined up.

And just knock on doors, right?

Um, you know, I remember when I was doing my job search, I went and knocked on the door of my program director and said, I'm going to start looking now.

Can you help me?

Um, who do you know?

Who can we call?

Um, you know, I know that positions may not be open right now, but let's start making some phone calls, right?

So ask for help.

And you'll find that people are willing to help.

Just sometimes people are not aware of how sensitive the timeline is and the sense of urgency of trying to find a job early enough so you can make plans, right?

Because for a lot of people it means, for us IMGs, it means that if we don't find a job, if we don't find that way of staying here, we have to go back to our country and, you know, some people are very blessed that you can go back and you have options if you go back and some people are not, right?

So, so be very proactive in that sense of ask for help early and, and email as much, as many people as you can.

Yeah, and I, sorry, I just wanted to piggyback on that, that you have not only you and your program or other ID people who want, um, or, you know, in the end, whatever subspecialty you're in that, that will hire you, but the, the recruiting people from the institution,

again, sometimes they may not know the urgency and they, you need to have the offer before much in advance than what they would normally do.

So sometimes they think, well, yes, we want you, we will have it by that year, but you need it sooner, and that's hard to communicate if they, if they haven't done this before.

Um, I think I would add that be very vocal about your needs and because this is your visa and your career, um, you will find people at your institution or elsewhere, even, you know, even, Don't hesitate from sending cold emails to program directors and division chiefs at other institutions, because ID is a great community and almost always

somebody will reply and get through, and if they don't, they cannot help you themselves, they will connect you with someone who can, and and that will help you immensely.

In addition to all the challenges you face, make sure you have a support system, because this process will take a lot out of you.

Um, patience, energy, time, there will be a lot of tears.

So make sure you have friends and family there with you to help you out.

And are there things that as individual, right, we're talking about your careers and folks are going to have a wide variety of, if they're interested in research, if they're interested in transplant, are there things that as an individual they have to think about?

Like, how do you add that into this process as well?

I will say that the main challenge with that is that, especially for the Conrad 30 program, most states require that you have to be an equivalent of a full FTE on a clinical position, and most of the times that requires some, it has specific languages, and

this This might depend on the state, but it has language regarding how many hours you have to spend per week doing direct patient care.

And so the landscape of how your job is going to look might be very different to how your time was divided during fellowship.

And especially if you have a strong interest in doing some stuff that are away from a clinical work in academic medicine or pursuing a research career, you have to be aware that it might have to happen in your own kind of free time, because in the paper, at least in your contract, it has to be that you're going to be doing a full time clinical job.

And that's something that people need to be aware of, but also that is something that needs to be a part of the conversation and might be also a challenge when you're trying to find a job, because there might be places where they are looking for someone, but they don't have a full FTE to provide with a clinical job, and you may end up into challenges of, uh, or trying to

find different pathways or opportunities that, like, combine positions with different, um, divisions just to try to fulfill that requirement of having a full FTE of a clinical position.

Yeah, I think this is really important because, and this is where getting people to rally around you really helps like having a chief or a director who's willing to help you a little bit with Um, how you navigate your time, like, for example, I'm on a J 1 waiver right now, and I'm 40%, like, 40 hours full

time clinical FTE, um, but I, I know, I really, I knew I really, really, really wanted to work with, uh, medical education and GME, and so I had to sign a separate clause and contract with GME, um, and so even though I'm 40 hours, like one FTE doing clinical work, I'm doing GME work outside of my normal hours, which it's fine.

I'm doing it because I love it.

But, It changes how your job will be structured.

A lot of people want to do stewardship work or IPC work, and sometimes that might not always be possible, and this was not something we're warned or told about, and I think people should keep that in mind.

I would also add that, uh, for that super specialty part of IDE that many of us have, um, try to take that as an opportunity, but also don't be so close minded.

Like, uh, the waiver options are relatively scarce.

Um, so, you know, be ready to practice any area of ID that you need to, and at the same time you can talk to or negotiate how to increase progressively the time in the specific area that you want to, and many times you can take this as an opportunity to, um, sell yourself a little bit better,

like, I can serve this specific area that the hospital needs, and actually that can be helpful for the hospital to support that they need a waiver.

Because that's another part that they need to do, like, they need to we are competing also against surgeons and psychiatrists and, uh, uh, cardiologists who may need a waiver position there.

So why do the hospital need to hire an ID this year?

It's, it's something important that they need to, um, to say, um, in advance to secure your position through a waiver.

You guys have started kind of traveling towards this, um, question too, but the next part is asking, you know, if you had a bunch of Fellowship program directors or division directors or your mentors in front of you, like, what are things that you wish they knew about that you could ask for help with?

I'm going to pick on Shweta because you mentioned that you have a program director position now, you know, maybe to just start this conversation off and hear from the rest of the group on things that they wish they could ask for or advocate for more of

well, being, you know, being an IMG, having completed a waiver.

So now when I interview candidates for transplant ID fellowship, I, I make sure that I asked him, okay, so, you know, I do need a, do you need a visa status or, and this is during their, like, interviews, just so that I can, you know, guide them a little more on.

So the, there will be limitations, like Transplant ID is a specialty, where finding jobs is going to be a little tough.

That's usually mostly at academic centers.

So what's your plan if you cannot get a Transplant ID job?

You know, we can try.

There are, there are, thankfully, these days, there are academic centers that offer J1 waiver spots for transplant ID, but there are really few centers, and I know Cesar can speak to that too, having done it recently.

So, I bring that up during our interview itself, so it ultimately prepares someone, you know, where's my career going?

What am I going to do after this fellowship?

And I think it's an important question that all program directors should ask when they interview for a potential ID fellow.

I also just get a sense that, you know, a lot of our IMG specific topics, um, are just not very well known amongst, um, different, you know, fellowship program directors and division directors.

Um, and, you know, it is super complicated, so I, I kind of get it.

Um, but when we, when we were writing that editorial, you know, part of our motivation was we wanted something that, you know, people can reference.

Uh, a lot of The thing that we wrote down, a lot of IMGs learn through experience, um, but, you know, they're, you know, we wanted something that could help educate our colleagues, especially those who aren't going through the same experiences that we are.

So I think just educating yourself, um, and being aware of some of the challenges that, you know, your IMG fellows or your IMG faculty members may face is just in itself like one of the biggest, the biggest part.

Ana Del Valle: Just to piggyback on that, I mean, the process of meeting a waiver doesn't change year to year.

So if, if you're listening to this and you're a program director, your IMGs are always going to struggle.

So if you're matching a fellow who's in a J 1, I would recommend that you ask that fellow, what are your long term plans from day one.

Do you want to stay in the U.

S.

or not, right?

Make your office a safe space for that fellow to be able to be honest and say, hey, yes, I want to stay.

Be aware of what your own institution can do for that fellow, right?

What can you offer that fellow?

Can you offer a J 1 waiver?

If you don't, then there's other pathways, right?

If your fellow wants to stay, can you offer an O?

Is that, is your fellow willing to stay on an O?

So, The conversations would be a lot easier, right, uh, for us when we're seeing that in the office if we know that our, our, our, our program directors are educated on what the options are and that they're also willing to try and find out if, you know, what their institution can offer to us.

And if not, then just help that fellow connect with other people, right?

The infectious disease world is pretty small.

Probably everybody knows an IMG who has gone through the waiver process.

Just connect that fellow with one of us who can help them out to navigate the process because it is extremely confusing.

It's very, it's very stress inducing, um, and just having a mentor that can kind of guide you through it and say, hey, it's going to be okay.

It's going to be challenging.

It's going to be tough, but you're going to figure out, you're going to find a job.

Let's just, you know, take it one, one step at a time.

I really like that.

I, I feel like it would really help IMGs, uh, like new fellows if they're, if you're a program director, if you sat down with them on day one, and especially I want to talk about people who are interested in research, the research faculty should know that as a non-US citizen, you are not eligible for certain NIH funded grants.

Um, and so that can definitely limit doing like a third year for adult ID fellows.

Um, and there are other avenues that they can explore.

It's just that the research faculty needs to be aware of those.

Um, and I know there are peds id, uh, PIDs initiatives and I'll let the peds folks talk about that a little bit more, but there are ways to help these fellows, we just need the faculty to know about them and be educated about them.

Yeah, I, again, agreeing, echoing all that, but also exactly, it has to come from leadership as well, not only peers, you know, for all of us, probably it's like somebody didn't know and like Teoh was saying, we learn from our experience, but we may not know other experience, and what worked for one might not work for the other.

Um, and often I, you know, often found like faculty didn't know, or they said, Oh yeah, let's talk to that person who did the same thing, but it's not the same thing.

Um, and so that's, it cannot only be peer to peer, right?

So you do need legal, you need, you need support.

And, uh, the fastest we start with that, uh, and then we haven't talked much about yet, but we also have the issue of, uh, if you have partially trained abroad, then needing to repeat residency, uh, which is another, another hurdle, right?

Um, and some people have to do either one or the visa versus residency or both, uh, such as Diego.

Um, and, uh.

And it's, it's also, you know, it, there's different pathways by ABP.

And I don't know if, I assume adults have the same, but maybe you can tell us, um, you could either repeat residency and maybe ask for a waiver of the one year if you send your records and it's approved by ABP, or you could do an alternate pathway, which is much harder and you need to basically prove that you

are a researcher and some years, uh, more years of experience, and the department chair has to nominate you for that, and then you're prospectively evaluated for two more years, and then finally they decide you can be, um, you can be board eligible, but you have to be hired by some institution before that,

so it's much harder in those two years.

Again, it's career setback time.

It's also, um, time for promotion.

You know, if you do those two years and then move on to faculty, your early faculty years are a little bit, um, you're in a more of a rush because of time out, out of training, et cetera, and, and expected publications on academic products.

Right.

I probably this is jumping ahead into like kind of more than not only the program leadership, but just kind of going back to the same topic and then as being Cristina this residency again and being the one that is doing residency again, that there is also like a big point about like the workforce and the kind of the retention of workforce in ID only in our program, I

know of at least four or five people that have finished fellowship and has not been able to start working but has had to go back to do residency and for a field that although is still having a great amount of people coming into our field, but it's also in a need to have a broader amount of peds ID doctors outside providing services to the public and serving in different positions.

Having people that is already fully trained in peds ID.

But then have to spend an additional two years just doing extra training that probably may not have been necessary is something that definitely we need more advocates to and to be able to speak with ABP and find some different avenues in which peds ID doctors that complete their training requirements can start working in peds ID and don't having to add an additional challenge to their career.

Ana Del Valle: Absolutely.

I think that's, that's a very good point.

And, and, and in addition to that, right, like we cannot be losing people because they're spending time going back to doing residency that they already completed, but we're also losing peds ID people who go and do waivers in general pediatrics.

So how can we close that gap, right?

How can we make the job search easier for people?

So that hospitals that are capable of sponsoring waivers are aware that they're capable of sponsoring waivers.

There, there were multiple times and I think, you know, other people in this right here are probably had the same experience that you reach out to a program and you say, you have a job posted and guess what?

You can provide waivers and they are completely clueless and they don't know that they're able to do it.

And, and how can we make those programs are aware that they're able to sponsor waivers, but also help them figure out the process of how to sponsor the waiver.

So that job is not lost and doesn't go unfilled for a long time, right?

Because, I mean, sometimes the path of least resistance for an IMG that is looking for a waiver is just to go do a general pediatrics waiver because it's just way easier to do it.

And I think as we've been talking, we've been like slowly zooming out, right?

And um, I think we've started to head in this direction, but I think the last sort of big question here is, what can national organizations, whether those are IDSA, PIDS, AAP, you know, similar groups do to help support IMGs along this process?

And I think it'd be helpful if you highlight things that are existing that you found useful, um, but also what are things that we could dream and imagine and create for the future?

So, um, I will say from the society perspective, I mean, PIDS and IDSA are instrumental for IMGs in many ways.

Um, and I can speak from the PIDS standpoint.

So I think a lot of, uh, PIDS has, we've been very fortunate to have a lot of IMG related initiatives within PIDS.

So, for example, we have an Inclusion, Diversity, Access, and Equity Grand Rounds that we do quarterly.

Um, and we've, um Um, essentially almost had an IMG related Grand Rounds every year, and I know that has been very well received and well attended, and we also have an IMG Early Career Development Award that is sort of a strategy to help IMGs get additional, or, um, or get any research funding.

Um, and then there are also movements, um, and a lot of IMG led initiatives to get, you know, more like liaison roles and to get an IMG subcommittee within our society.

And I think really being involved at the leadership level, um, I think the other area that is really important, because a lot of us, and, you know, And the reality is a lot of IMGs don't have a lot of political capital, especially in this society, and we aren't really considered constituents by policymakers.

So I think really having legislative efforts come from our societies, especially multi society efforts, are extremely important.

So when we're talking about expanding Conrad from 30 to 35 positions and actually making sure it's, um, So Renewed in time, because it has to be renewed every couple years.

Or around advocacy efforts around getting our professional board organizations to actually recognize international medical training so that people like Cristina and Diego don't have to re do residency, which to me sounds not particularly pleasant, if you ask me.

So, I think those are such important areas that the society who have a lot of more sway could really influence the discussion and really help IMGs along.

That's great.

Um, I don't know if it has all these great initiatives.

Um, well, I think on the adult side, What would really help is if, uh, if we could have one website with all the jobs and with, like, a listing of the visa supported, um, and institutions were more transparent about it, that would be really helpful.

I know from personal experience, beyond, thinking beyond the J 1 process and the J 1 waiver, as an IMG for, you know, for, other green card applications and things like that, you will need lots of letters of support, um, leadership roles, visibility, and that is something I think IDSA can support IMGs with, and that would be great.

I know that there are also resources through the Program Directors COP from IDSA that they actually, the Program Directors have created by themselves, um, with a lot of like questions and answers, um, like a FAQ.

type of document for them, um, so they share, like, the ones, the program director who have had experience with waivers and all this process have shared with the rest.

Um, so, and I know that there is a survey in process, um, to try to get a little bit more of the sense of the needs and the requirements from J1 from the adult side.

You know, I, I, I, picking back to the part of like the job search and the JYN waiver possibilities, I wanted to give a shout out to the PIDS society because in a very informal conversation that a couple of us had with the PIDS staff and in which they were hearing about our process and our challenges, they made a

very small change in their, in the PIDS job posting website and is that when they send out the kind of the template for people to fill for a position that is available.

They added at the end, uh, uh, just a sentence that says, is this a J1 waiver eligible position or not?

And not every institution fill it out.

But, uh, as someone that was recently in all the interview trail and looking for jobs, that was extremely helpful and very encouraging.

When I will see a posting that already was saying that a J1 waiver, um, was available.

And my advice for any division chief that is about to post a job is to ask yourself and ask within the division, are we allowed to, uh, create this position and have a J1 waiver available or not?

And to put that in, in, in, in the advertisement of the position, because that is going to be extremely helpful for all the applicants.

Now, like going from the far end of the spectrum from sort of national groups and zooming into something a little bit different, that you need communities and, and groups or connections that help you through this process.

Um, and I was wondering if there are peer groups or communities of practice that you guys found particularly helpful that you want to give shout outs to?

I started getting most of my information from Facebook groups and there's a group, I see everybody nodding, everybody knows.

And it's a very general kind of group and because I was trying to find more people who knew about this, I stumbled onto like the Hispanics in ID group, which is already doing a lot of advocacy work.

And then there's a nascent South Asians in ID group as well, who have really been instrumental in helping us find.

A, support, and B, also connections in terms of job searches, et cetera.

Um, so I, you know, somebody already mentioned how important it is to have community when you're going through this process, and I think that has really helped me.

I think I need to jump in and say that Radhika has been very instrumental in starting the South Asians in ID group.

Um, so a big shout out to paying it forward, Radhika.

And by default of you guys being on this, I feel you've sort of semi volunteered yourself to be contacted and asked, and I, um, you guys have all mentioned cold emailing folks, and um, I think that's, I'm sure, a big part of it.

Sounds like everyone's experience is, you know, even just starting with that.

conversations with individuals and then identifying these communities.

Um, within PIDS, one thing that happened the last two years of ID Week is that there wasn't a space given to do an IMG networking event.

Uh, uh, That, uh, to have different people, IMGs in different stages of a career to just come and tag along and meet each other.

Because at the end of the day, as everyone has been saying, we, we learn a lot of things by word of mouth.

No, no, no matter how much research you do in the internet, there is no centralized place to find all the information that you need.

And just making those contacts is significantly important.

I don't think we have had a big like, take off, but it does exist within the PIDS website and forums.

There is a sub forum for IMGs, which I think we still have to utilize, but we're just trying within the society to kind of increase those opportunities to do networking and just tell people that they are not alone in their pathway.

Yeah, I think an underutilized, um, network for IDSA is the IDSA Mentorship 365, where, you know, you meet for lunch, you actually connect with your mentor for the whole year, um, and I'm not sure if all trainees are aware of it or the benefits they can have, you know, by connecting with a mentor because, you know, you,

that's where you make some connections and then you can, you voice your problems and there will be somebody out there who can help you with your, you know, visa process.

Um, I just want to say also, like, for Peds ID, uh, at the St.

Jude's PIDS Conference, I remember, you know, when I was a first year fellow, and I'm, I'm very happy, and as you all mentioned about, you know, the changes that PIDS has, has done, but as a first year fellow, um, Very few, I feel, faculty knew about what can we offer for IMGs, even though people was, uh, were asking, however, that has changed a lot, so

there's really, uh, there's much more knowledge and, um, input from the society to help all the IMG trainees, which has been very helpful, and the other thing that I mentioned, so that time when I was a first year fellow and nobody knew that much about waiver situations, um, the speaker from the CDC EIS program was the only one who could speak more to it.

And so the CDC is also a good resource, um, although has some different pathways situation, but again, more to learn from, um, and explore, and they, they really know a little bit more.

So that can be helpful.

And really at the end, I, I like to just open it up because there was no way we were going to cover every piece of this conversation today.

It's just the start of a conversation.

But if there are other points that you guys want to make sure that we either reinforce or don't, don't miss before we wrap up, I'll sort of open up the floor to the group.

Ana Del Valle: I would just say when you're on a J 1 visa, I feel at least from my perspective, I was always thinking about what can I do to get a job, right?

Since the beginning, like, how can I find a job?

So, I think one thing to keep in mind when you're even looking for your fellowship match, look at the faculty, right?

Look who's there.

If, you know, that program has faculty on J 1 visas, Talk to that faculty, right?

Um, hear about their experience.

Did they train there and they stayed?

Did they have to move?

Did they have to do or go other places?

Always keep your eyes open, you know, about the the faculty and the places that you go if you're looking for a waiver.

Um, that can be a big green flag.

Another thing is don't be afraid to speak up and ask questions when you're in the interview trail.

Um, ask the programs if there is a pathway to a green card if you go there, I don't.

Don't.

Anticipate the next move past the waiver if you want to stay, right, like, how are you going to help me after this if I want to stay here beyond the J 1 waiver, if I want to make a career at this institution.

Again, just reinforcing, talk to Immigration Services, that has to be one of your most important meetings when you go, um, to interview for a job is that that meeting with immigration services is going to give you a lot of information and a lot of insight as to what that institution is actually willing to offer you.

Um, and, and don't, don't be afraid to ask those questions, uh, because at the end of the day, your, your future kind of depends on you understanding the situation at every specific institution.

Yeah, I think Ana really, like, drove home the point about retention.

I think, um, We're always talking about how to retain, uh, how to recruit international graduates and how to improve DEI, but we're no one's talking about retention, and I think that's, that's really important.

But I will say there are a lot of systemic changes that IDSA had, has made, and these will take time, but I think there's still work to be done.

Yeah, I just want to say that's such a key point, um, and, and as we pointed out, 25 percent of Peds ID are IMGs, uh, or 25 percent of peds trainees are IMGs, yet if, I, I feel like the, if you look around, most divisions do not have 25 percent of their division members as IMGs, and I think that speaks so much to how leaky our pipeline is, and, you know,

I, you know, I, I think I applaud the leaderships in adult ID and peds ID, and really working on diversifying our, our workforce and really working on recruitment from the bottom up.

But we will also really have to think about how leaky our pipeline is.

And it's not just leaky for IMGs, especially, but it's leaky for people of racial minority groups, people who are women, people who have other factors that really drives them out of our workforce.

And if we're going to keep recruiting people, but they don't stay in ID, I think that, you know, I think those are aspects that are really crucial, and that especially impacts IMGs, because we have so many factors that ends up driving us out of out of ID, and I think that that is such a missed opportunity.

So that's really something that we have to think about within our society, but also we need help from our leadership.

And you know, I, I will just want to say that if you are currently either a resident that is in a J1 that is thinking of going into ID or recently matching ID, uh, don't feel discouraged.

It's, it's, it's hard.

It's, but it's, you're not alone.

Like we, we all have all found people that support us.

We just want more people to be able to be aware of all the challenges.

And I think that both societies are doing a great job on trying to do that.

But always look ahead and very importantly, keep all your paperwork, keep updating your CV.

You are going to need every single document of every single presentation that you've ever given for all this process.

So don't lose, um, anything of that in Treasure Use DS 2019 in a save because they are going to be required at the end of the day and just keep moving forward because you'll find a way to get through at the end of the day.

I just wanted to piggyback on the point that Shweta mentioned before, like, be very explicit and vocal about your needs with program directors, friends, mentors, like, once you tell them, I need the waiver.

They are just like my program director was like so great to connect me with more other people and my mentor.

Start texting all her friends to see who is offering a job and if they can do a waiver And that's the way how I got my interviews greater than you know Looking for something that was posted and through the traditional method because I had to do it so much ahead of time to get this position.

So just look to your circle, to your network, and then try to expand that a little bit more and just tell them what are your needs.

Right, um, I think also don't, don't believe everything you hear.

Just ask for yourself.

Um, and to an extent, don't even believe all of us are here on the podcast.

Ask for yourself because information changes every year and, you know, like an academic institution that doesn't do waivers this year might be doing it next year.

So send that email and don't be afraid of asking.

I wanted to thank you, um, Sara for all this opportunity and, you know, as, uh, Diego said, and, um, and to everybody's point as well, like things are improving and in much, in part, you know, to the, thanks to the advocacy of this group and has gone, gone up the scale and made things better.

So we just need to keep, keep growing.

A huge thank you to all of our amazing guests for joining Febrile today.

You can check out the website, febrilepodcast.

com, where you will find the consult notes, which are written complements of the episodes with links to references, our library of ID infographics, and a link to our merch store.

Febrile is produced with support from the Infectious Diseases Society of America.

Please reach out if you have any suggestions for future shows or want to be more involved with Febrile.

Thanks for listening, stay safe, I'll see you next time, and have a happy holiday season.