Embracing International Medical Graduates in Nephrology: Time to Get Serious

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Sujith Palleti, MD
Loyola University, Chicago, Illinois

Dr. Palleti is a 2nd-year nephrology fellow in an ACGME-accredited program in the US who entered training through an exceptionally qualified candidate pathway. He completed his medical school training in India and his internal medicine residency at MNRMCH affiliated with KNR University of Health Sciences in India. 

The decline in interest in nephrology is well documented. However, what is most striking is the waning interest in nephrology as a career by international medical graduates (Figure). For example, the number of international medical graduates (IMGs) decreased by almost 50% from 2010 to 2016 at the same time as fellowship positions became unfilled. While correlation is not always causation, this is striking. It is now obvious in the nephrology community that many of these positions are being filled by foreign-trained physicians who are joining as exceptionally qualified candidates per ACGME guidelines after completing their home country residency and getting credentials verified. This unique group of IMGs has helped to fill this substantial portion of nephrology fellowship positions which would otherwise go unused.

Figure.Data from Kurtis A. Pivert. 2018. “AY 2019 Nephrology Match—Preliminary Results.” November 28, 2018. https://data.asn-online.org/posts/ay_2019_match.

Hypothetical Case of an IMG:

Dr. X is an international medical graduate (IMG) who graduated from medical school in Sri Lanka. She studied hard to join an internal medicine residency in Sri Lanka. However, she always dreamed of going to the US for training and thus completed the required USMLE exams to apply for an ACGME-accredited nephrology fellowship in the US after completing her internal medicine residency in Sri Lanka as an exceptionally qualified IMG. She came to the US with hopes of getting an unrestricted license after 2 years of nephrology training in an ACGME-accredited program and working as a nephrologist in the US as the demand for physicians is huge and felt everywhere. As she navigated through the process of spending all day in a busy nephrology fellowship she found that the choices in front of her to work in the US after training are much more difficult and uncertain than she thought. She cannot get a permanent/unrestricted license in many states as the requirement is 3 years of ACGME-accredited training (22/50 states) or completing a US internal medicine residency. Unfortunately, nephrology is a 2 year fellowship which will not meet this requirement. She was also told by most that the ideal situation is to re-do residency in the US but getting residency has gotten tougher year by year for IMGs, especially for those requiring a visa. While doing a fellowship in the US is one of the toughest phases in the life of a physician, having limited options and the potential of having to leave the US permanently can take its toll on anyone. Under current circumstances, the fellowship training without ABIM certification carries no value which means a waste of precious time and effort. The situation is not ideal for the healthcare community as well with the growing need for physicians which makes it a lose-lose situation.  

Here are the difficulties obtaining a job for these exceptional pathway candidates.  

  • The inability to obtain permanent/unrestricted licensure in many states which requires 3 years of ACGME postgraduate training is a huge drawback.   
  • Unable to join private sole/group practices due to challenges in obtaining hospital privileges/ become dialysis director without ABIM-nephrology board certification.   
  • Limited opportunities for a faculty position at teaching institutions as it needs the approval of the credentialing committee  
  • Limited J1 waiver positions are available in teaching hospitals. 

Here are my recommendations:

  • Request the state licensing boards to provide exceptions for permanent/unrestricted licensure for these physicians after completing 2 years of ACGME-accredited fellowship training. 
  • Collaboration with the hospital credentialing committees to hire these physicians at the time of need.  
  • Request for more J1 waiver spots to be allotted to teaching hospitals. 
  • Measures to allow more programs to sponsor H1b visas for fellows instead of J1 visas which will eliminate the need for J1 waiver. 
  • Adequate training to ensure the fellows are ready for the academic pathway. 
  • Create more awareness regarding this among healthcare communities.
  • We need to have better data in nephrology as to how many trainees have entered in the exceptional pathway (de novo US nephrology fellowship without US internal medicine training) and what their outcomes are.
  • Allow exceptional pathway fellows who complete an ACGME-accredited fellowship to become ABIM nephrology board eligible right after completion of fellowship and not wait until a 3-year period in a teaching hospital (Pathway A)

Post reviewed by RFN editorial board.


  1. unfortunately funding for nephrology fellowships mirrors the length of time the ACGME accredits a program, which is 2 years in duration for nephrology. Thus, the additional year would not be ACGME approved and not count towards the 3 years. Thus, making this an unlikely solution.

  2. Will the easiest solution be to make nephrology training 3 years for IMGs without US residency?

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