The "American dream" has seen a steady flow of scientists and doctors to the United States. Asrar Rashid, Mark Twite, and Sunil Bhudia have tips for doctors thinking of making "the dream" come true

The United States is a hot bed for learning, innovation, and creativity. The main driving factor is economics. Academia in the United Kingdom has not been as successful in working with private institutions to release research ideas into the market place; this has led to a poor infrastructure for the development of young research scientists and doctors. This is also true of many other countries--this article uses doctors from the United Kingdom as an example.

Step 1: Decide what you want and choose your visa

The choice of visa may be out of your control. The best visa for working in the United States used to be the H-1 visa; however, this is getting more difficult to get hold of and most institutions are now giving the J-1 visa (box 1).

Do you want to settle in the United States?

If your aim is settlement in the United States, you should try to get an H-1 visa. Just be aware that getting an H-1 visa is now difficult unless your chosen specialty is perceived to be a high need specialty and there are not enough mainland clinicians already. There are two important general points about visas. Firstly, do not try to work out the type of visa until you have met with the faculty and spoken to colleagues (especially residents and fellows). Secondly, if for some reason your visa is rejected the American embassy will stamp "Visa Rejected" on your passport, so try to get as much advice about obtaining the right visa before you apply.

Box 1: The main visa options for doctors

• J-1 visa--a temporary training visa given to doctors and scientists. Doctors must return to their country of origin and cannot work in the United States for a period of two years (there may be exceptions)
• H-1 visa--this visa can in time be developed into a green card
• Green card--this gives the doctor the chance to stay permanently in the United States
• Waiver visa--possible if you have skills that place you as an expert or someone with outstanding ability. This visa is sometimes sought by doctors who are consultants in the United Kingdom and wish to work at the same level in the United States9;J-1 visa--a temporary training visa given to doctors and scientists. Doctors must return to their country of origin and cannot work in the United States for a period of two years (there may be exceptions)

What does the J-1 visa allow me to do?

Once you have completed the training that you wanted to do and left the United States you cannot return to work in the US for a two year grace period. The purpose of the J-1 visa is for you to be trained so that you can return to your home country and give back the expertise. So let's say you have become fully trained after your designated period of training and you wish to stay in the United States long term. If you are a scientist you can do so only if your professor can make a case for you being important and that there is a perceived need for you. This will, however, be difficult. Doctors who have gained full training in the US health system can be hired in an area with a perceived need; this is usually an area "off the beaten track," though it will be up to you to choose the area through contacts you will have made during your training. Some doctors just go back to their home country and work for two years before returning. If you aim to go to the United States to complete your specialist training and then return to the United Kingdom to a consultant position, you can spend the two year J-1 period in such a consultant post and then apply or be invited back to the United States at attending (consultant) level. To achieve the latter, however, you must try to choose specialties that require doctors.

The green card

The green card allows you to work in the United States long term and does not confer US nationality. It can expire if you leave and do not return to the United States. You can work up to a green card from an H-1 visa but not from a J-1 visa.

The green card lottery

The green card lottery is available to doctors only from certain countries. It is an attempt by the US government to encourage people to migrate from different societies and cultures. The list of countries eligible to enter this scheme varies from year to year, and you can get further information from the US embassy. At the time of writing, UK citizens are not eligible.

Family sponsorship

Your family can sponsor you if they have US nationality.

National waiver scheme

If you are an expert in your field you can be given a national waiver from the above visas and go directly to the United States to work. You do not have to be a leading world expert, but you should be able to prove that you are worth waiving.

Hiring an attorney

The J-1 visas are usually the simplest, though even they can be fraught with difficulties. Other visas, such as the H-1 and the national waiver, may require more expertise; you can apply for these yourself, but getting a good attorney may cut a lot of corners and save you time.

Step 2: Do you need to take licensure examinations?

Just as the United Kingdom has the PLAB (Professional and Linguistic Assessment Board) test, the United States has the USMLE (United States Medical Licensing Examination) for non-US doctors. If you just want to do research in the United States you will not need to take accreditation examinations and the procedure for acceptance into a research programme is more straightforward. However, anything to do with clinical exposure requires you to take the USMLE step examinations (box 2). These examinations must be done before you can enter an accredited programme. There is also a step 3 examination, which you usually take once you have arrived in the United States and are in training. The step 3 examination is a multiple choice question based examination and ensures you have a good working knowledge of US clinical practice.

You should email the director of the programme to work out what examinations you need. If your plan is just to gain some experience in the United States without accreditation by a US authority then it may be possible to bypass the usual procedures required of foreign graduates.

Programmes are accredited by the ACGME (Accreditation Council for Graduate Medical Education). ACGME accreditation ensures that all US programmes have a similar structure and provide the right education. Programme accreditation by the ACGME is mandatory to be able to get state aid for health services provided to individuals without private medical insurance.

Step 3: Fellowship or residency?

The basic training programmes are called residencies; after residencies doctors can work independently. Doctors wishing to specialise further take up a fellowship programme. The duration of these programmes depends on the type of training required. If you are starting your training then it is best to do a residency followed by a fellowship. If, however, you intend to return to the United Kingdom and have already done enough clinical work in the United Kingdom, then a fellowship may suffice. Should you ever wish to work in the United States, however, you would have to do a residency in the relevant parent specialty in order to be "board eligible" and take certifying examinations. The alternative, as discussed earlier, is to become an expert in a specialty and be invited to a US post.

The examinations at the end of the residency are called the "boards" and provide accreditation in that specialty. The fellowships also have examinations though you can take the examinations in these only if you have done a residency beforehand.

Negotiating with your regional subcommittee

This is relevant for doctors who have a career path planned in this country and want clinical or research experience in an area of expertise that is practised in the United States. Some doctors apply to do research so that they are more marketable for a UK specialist registrar rotation; this is especially true of surgical specialties. You should talk to your regional advisers and try to find examples of colleagues who have provided a precedent for going to the United States.

Case studies

Asrar Rashid,
University of Aberdeen (West Midlands rotation in paediatrics, specialist registrar year 4)

I started training in the United States in September 2002 at Denver Children's Hospital, having spent 10 years training in paediatrics in the NHS. My problem was finding funding for research and the desire to complete my training in a subspecialty in an institution of higher learning. My subspecialty of interest is paediatric intensive care and this demands an up to date knowledge and skill to provide sick children with quality care. Fortunately, I have the support of the West Midlands Regional Training Committee and recognition from the paediatric intensive care subcommittee for my work in the United States. I plan to undertake two years of a three year fellowship: the first year is mainly clinical based and the final year is mainly research. My research interests are viral immunology and I hope to get a MD out of this. I would like to take up a UK consultant post after finishing in the United States.

Box 2: The key US licensure examinations for non-US doctors

• USMLE step 1--basic science multiple choice question examination equivalent to the preclinical stage of the medical degree
• USMLE step 2--clinical examination equivalent to the clinical stage of the medical degree
• Test of English as a Foreign Language (TOEFL)--spoken and written English examination
• Clinical skills examination (CSE)--must be undertaken in Philadelphia (expensive). Purely a history taking and physical examination test, based on skill stations

Sunil Bhudia,
University College Medical School, London

I started research at the Cleveland Clinic Foundation in July 2001. I have completed my basic surgical training and am a member of the Royal College of Surgeons of England. After completing this period in research, I will be applying for a specialist registrar post in cardiothoracic surgery in the United Kingdom. My main research project will be written up as a thesis towards an MD, which will be submitted to London University. This is a two year research fellowship with opportunities to carry out research in clinical or basic science. While in the United States, I have kept up with NHS developments in the United Kingdom.

Mark Twite fellow, paediatric critical care, Denver Children's Hospital, Denver, CO, USA
Email: drasrar@lineone.net

Asrar Rashid fellow, paediatric critical care

Sunil Bhudia research fellow, cardiothoracic surgery, The Cleveland Clinic Foundation, Cleveland, OH, USA

Further information

• Consult www.medicpages.com