Addressing Forensic Pathologist Shortages: Visas

October 06, 2021

Despite a growing national need for accurate and timely medicolegal death investigations and autopsies, states suffer from severe forensic pathologist workforce shortages due to difficulty growing, recruiting, and retaining practicing board-certified forensic pathologists. These shortages translate to larger case volumes for medical examiner and coroner offices and can result in reduced access to high quality and timely critical mortality data. Given the surge of opioid overdose deaths over the past decade (from 6.1 to 21.6 per 100,000 population), the superimposed burden of COVID-19 deaths, and the consequent increased demand for forensic pathologists, workforce shortages have only worsened.

Many U.S.-trained medical students and pathology residents forego a career in forensic pathology due to uncertainty about job satisfaction, low pay in the face of challenges from educational debt, and wide variation in the quality of practice settings, all of which contribute to a constricted forensic pathology workforce pipeline. While other medical specialties can supplement their workforce with international medical graduates, those interested in pursuing a career in forensic pathology have additional barriers, including a costly and complex application process for maintaining legal immigration status while training or practicing.

After years of specialized education and training, visa-related barriers are an added social, mental, and financial burden that can hinder international medical graduates’ ability to remain in the United States to pursue forensic pathology training or practice forensic pathology. As a result, many international graduates must seek employment outside of the United States. To better harness the talent of international medical graduates and minimize forensic pathology shortages, states should streamline visa application processes and policies.

Visas and Transitions

The B-1 visa, also known as a “tourist” or “visitor” visa, is good for six months to a year, and students widely use this to complete clinical clerkship rotations during their last two years of medical school. However, B-1 visas do not authorize individuals to work or earn a wage. After their visas expire or they complete their clinical clerkships, B-1 visa holders must transition to J-1 visa status to continue training or remain in the United States.

The J-1 visa allows an individual to earn a salary, and international medical graduates typically use this during their residency or fellowship training. Graduates can renew their J-1 visas annually for up to seven years and international medical graduates must pay yearly sponsorship fees. Once their visa expires, a visa holder must apply for an extension to remain in the United States or international medical graduates must return to their country of last permanent residence for two cumulative years before being considered for permanent U.S. residency. The Educational Commission for Foreign Medical Graduates sponsors J-1 visas at no cost to the host hospital or the medical examiner’s (ME) office, but not all host offices honor or accept this visa program.

Specifically established to remedy primary care physician shortages in underserved areas, the Conrad 30 Waiver Program waives the home residency requirement after a graduate completes the J-1 exchange visitor program. An immigrant physician who wishes to remain in the United States can apply for a waiver in exchange for three years of service in a geographically underserved area. State, local, and territorial health departments are eligible to sponsor the Conrad 30 Waiver Program and are each allotted 30 waivers, of which only 10 can be allocated to a direct patient care specialty. The program runs on a first-come, first-served basis until the state exhausts its waivers. Jurisdictions define “direct patient care” specialties differently, and not all recognize forensic pathology as eligible.

Once a physician obtains a Conrad 30 waiver, an H-1B visa (i.e., “work visa”) will follow, allowing that individual to remain in the United States to practice forensic pathology. The H-1B visa is good for six years. However, after three years, the sponsoring ME office must submit an extension, for an associated fee, to continue employing the physician international visa holder for the additional three years. The visa holder must obtain a green card before their H-1B visa expires to remain in the United States.

Recommendations for State, Local, and Territorial Health Officials

State and territorial health officials should consider the following recommendations to increase their forensic pathology capacity:

• Recognize forensic pathology as “direct patient care” and authorize Conrad 30 waivers for forensic pathology based on the jurisdiction’s size and need. Include this specialty on waiver lists regardless of an applicant’s geographical placement.
• Consider potential barriers to entry from J-1 waiver applications. For example, the current waiver process opens once annually in October, but forensic pathology fellowship programs begin in July, allowing an applicant only three months to secure a job and be considered for waiver status.
• Fund grant opportunities for ME offices to sponsor international medical graduates. Currently, an ME office bears the financial burden of H-1B visa sponsorship and extensions (upwards of $10,000 for the sponsoring office). This forces offices that are already under budget and resource constraints to turn away or let go of skilled international medical graduates despite increased caseloads.
• Provide education on the communication and paperwork requirements between the state visa liaison, applicant, and sponsoring ME office.

Highly skilled international medical graduates play a critical role in public health surveillance. States and territories should harness the talent of these essential specialists to help minimize forensic pathology workforce shortages and rebuild state capacity to respond to public health crises.