Get the help you need. You need a waiver job, but researching H.P.S.A. designations and checking regulations with Conrad coordinators has got you running in circles. A few State Primary Care offices maintain job boards, but most do not provide job placement services. Consider letting a professional locate a waiver job opportunity on your behalf, but be sure to understand what services they will provide. Some recruiters make a practice of finding waiver jobs for foreign medical graduates and their services can be invaluable to you. Just keep in mind that a recruiter may have obligations to both you and your potential employer. The recruiter will ultimately profit from placing you in any job, not necessarily from finding you the most lucrative contract or the best working environment. Do not assume that the recruiter is negotiating with only your interests in mind, rely on an attorney to look out for you. When you are presented with a contract, have the contract reviewed by a health care lawyer. Just as an immigration attorney will assist you with your visa needs, you should also engage an experienced health care lawyer to review your proposed employment agreement. This lawyer is paid by you to represent your interests. As your employment agreement has been drafted by the practice’s attorney looking out for the practice’s best interests, you should have your own lawyer review this agreement to protect your interests and minimize potential problem areas in your agreement.

A health care attorney will represent only your interests, but an immigration attorney may be different. It is common practice in the immigration industry to act as a dual representative. A cautious immigration attorney will detail the terms of the relationship, letting you know that she represents both parties. Dual representation agreements are helpful in expediting case approval, but it can mean that you may need to seek a new immigration attorney in the event that you quit or are terminated.

Immigration attorneys may be paid by either party. Negotiate to have your employer reimburse you for immigration related expenses. Some employers are agreeable to paying a lump sum towards your pursuit of a green card as part of your benefits package.

Contract considerations. What types of things should you be on the lookout for in your agreement? Make sure you can get out of the agreement if the situation turns out not to be what was promised. Some employment agreements will not allow you to terminate your employment; avoid this at all costs. Also make sure your contract has a provision allowing you to terminate your employment on short notice if your employer violates its promises to you.

Make sure your employment agreement clearly spells out your work responsibilities. You want a clearly written understanding of where you will work, how many hours a week you are required to work and the maximum amount of call coverage you are required to take.

You may be asked to sign not only an employment agreement, but an agreement from the hospital as well, if the hospital is providing financial assistance to your new practice to assist with your recruitment. Make sure to show both contracts to your health care attorney, as the hospital agreement in particular may have financial penalties to you if improperly structured.

If the practice you are interested in joining has had one or more physicians leave in the past, see if you can track down one of the former physicians and learn from him or her why they left the practice. You may be surprised to learn that the practice did not live up to its contractual bargains in the past or that the practice tried to get the physician to sign a new employment agreement which was substantially worse than the original agreement. If you learn of prior misdeeds of the practice, think twice before signing on the dotted line.

Get familiar with the waiver and visa process. It helps to have a bit of background on why you are going through this strange process of seeking a waiver. It all stems from having completed residency training in J-1 status. The J-1 visa carries with it an onerous obligation: the two-year home residency requirement (HRR). Before you are eligible to change to another visa status, you must first deal with this obligation. Assuming that you do not want to return to your home country for two years, you can apply to have this obligation waived. You cannot apply for a waiver without the involvement of a sponsoring agency, in most cases a Conrad 30 program.

Each state is eligible to sponsor only 30 waivers per fiscal year and will consider the underserved needs of their residents in deciding which applications to select. Some place a heavy emphasis on Family Practice and OB/GYN. States set their own policies for waiver submissions and enforcement, but all must minimally meet the criteria set forth by the U.S. Department of State. Waiver jobs must be first advertised to American workers and must be performed in Health Professional Shortage Areas (H.P.S.A.). There are some recent developments which make it possible to serve outside of a H.P.S.A. in limited circumstances. Consider that some states are simply more "doctor friendly" and will make your application experience more efficient and, thereby, less stressful.

Before narrowing a job search to a particular state, you should consider the competitiveness of the program (you can guess what states are popular) and the timing of the application (is there a filing window or do they accept applications year-long?). You may have your heart set on New York, but your best option may be Nebraska. Ask your immigration attorney for guidance based on their experience with different programs and your individual needs.

It is good practice to start planning for a waiver application one year in advance of completing your training. This will allow for six months of recruitment, if needed, and another six months of processing by various agencies involved. If you haven’t found a waiver job until May and your status will expire in June you may have to exit the U.S. for a period of time. This doesn’t mean that the case cannot still be successful, but you do need to be realistic in your expectations for an uninterrupted stay in the States. Your attorney can also work with you to consider other options such as an extension or re-entry in J-2 status. Another good reason to plan in advance: you may be able to get two uses from the recruitment efforts by utilizing the advertisements for both the waiver and a PERM labor certification.

The waiver is only the first step in your bureaucratic journey. Once your case has received the recommendation of a Conrad program, it will be forwarded for review by the U.S. Department of State. This agency is averaging 45 days for review, though security clearances can take much longer in selected situations. Finally, your case will be sent to the C.I.S. service center (formerly known as I.N.S.) which has jurisdiction for your region. This last step in processing can take from 30-90 days.

You cannot work on the basis of the waiver alone. You must first have an approved H1B visa. The H1B visa process should be started after you have received recommendation from the U.S. Department of State. Your application must be filed before your DS-2019 form expires. The H1B is a much more straightforward process than the waiver and allows for expedited handling for an additional $1000 fee.

Take this job and shove it. You have gotten your visa and started your dream job, but things are quickly turning into a nightmare. What can you do? Many foreign nationals incorrectly believe that they don’t have the same employment rights as U.S. citizens.

When you suspect that your contract is being breached, seek legal advice early on. Your attorney can remind your employer about the prevailing wage that they are obligated to pay by Labor Department regulations. Breaches of the waiver guidelines can jeopardize the employer’s ability to sponsor J-1 doctors in the future. An errant employer may just decide to get compliant with the contract and avoid losing you.

Your best defense is to be prepared. Organize documentation of the practice’s breaches. Your attorney will determine whether the situation rises to the level of "extenuating circumstances" that is required to receive a transfer of your waiver. It is also prudent to keep the Conrad 30 director advised of the situation. They will need a written record of the problems at the practice. The Conrad program staff can be helpful in locating a new employer that qualifies as a transfer site. Since each state has guidelines on the steps you must take before applying for a transfer, you should not make any move before getting clearance from the proper parties. Once you have gotten this authorization, you can secure a new employment agreement, file for a new H1B, and begin a new job.

Just because you accept a position as a foreign doctor does not mean you must suffer unfair working conditions. By having a well-drafted contract before trouble arises and documentation of the reasons why you must change employers, you may be able to leave your bad position behind.