Non-U.S. Pharmacists Face Residency Hurdles

For pharmacists born and educated outside the United States, earning a spot in a U.S. pharmacy residency program often requires patience, persistence, and a lot of help from the institution that wants to bring them on board.

That help includes navigating the intricacies of visa requirements and ensuring fulfillment of the academic, linguistic, and legal requirements for licensure in the United States.

“It’s incredibly confusing,” said Mike Katz, professor and director of international education at the University of Arizona College of Pharmacy in Tucson.

Katz said the school’s current crop of fourth-year pharmacy students includes five non-U.S. residents who are pursuing postgraduate year 1 (PGY1) residencies.

“If there are five in my school, I’m sure there are plenty around the country,” he said. “There’s clearly a worldwide recognition that residency training, particularly in America and particularly ASHP-accredited residency training, is sort of the holy grail, and I think people really want it.”

The easy way. Pharmacists in Canada are eligible to receive, at the U.S. border, a visa that allows entry into the United States to take a specific job, such as a residency position. Mexico’s pharmacists face tighter entry requirements, including a visit to the U.S. consulate to obtain a visa.

For other foreign nationals, Katz said, the simplest scenario involves students who entered the United States with an F-1 student visa and are ready to graduate from an Accreditation Council for Pharmacy Education (ACPE)-accredited school. These students will be eligible for licensure in the United States, which is a prerequisite for residency training.

“The nice thing about the F-1 visa is that after you graduate from school, it provides a year of what’s called optional practical training, or OPT,” Katz said. That year can be spent completing a PGY1 residency program.

To satisfy immigration laws for OPT, the residency program must confirm, in writing, that the pharmacist is an employee for the duration of the training.

“It’s simple, it’s easy, it costs very little money,” Katz said.

The filing fee is $380, according to the U.S. Citizenship and Immigration Services.

The hard way. Once the OPT year ends, pharmacists who want additional training in the United States generally seek an H-1B visa, as do pharmacists who were educated abroad and want to pursue U.S. residency training.

The cost of obtaining an H-1B visa runs into the thousands of dollars. By law, some fees must be paid by the visa’s sponsor, and some must be paid by the prospective employee.

“It’s just mind-boggling as far as who pays what,” Katz said, adding that his school’s international office is a big help in sorting out the legal requirements for visas.

Katz said in January that he was working on the paperwork to sponsor H-1B visas for two current PGY1 residents who want to remain at the hospital to complete a PGY2 residency program.

Because these pharmacists committed early to the PGY2 program, the university was able to start the H-1B paperwork to ensure that all will be in order for the July 1 residency start date. In addition, Katz said, the university is paying the U.S. Citizenship and Immigration Services an extra fee for so-called premium processing to expedite the process.

“If the pharmacists don’t get the H-1B visa by July 1, then they’re basically in the country illegally,” Katz explained. “I’d rather spend the money for their safety rather than take the chance.”

It can be difficult to obtain an H-1B visa between March, when the ASHP Residency Match occurs, and the traditional July 1 residency start date, Katz said.

Barbara Irby, director of pharmacy experiential education at Massachusetts General Hospital in Boston, fondly recalls a pharmacy resident who obtained an H-1B visa to work at the hospital several years ago.

“She was a great success,” Irby said, adding that the resident eventually joined the staff as the hospital’s first infectious diseases pharmacist before returning to Lebanon for family reasons.

The resident had graduated from Lebanese American University (LAU) in Beirut, which is ACPE accredited and whose graduates are eligible for licensure in the United States.

Despite that advantage, the hospital encountered difficulties sponsoring the H-1B visa, with delays that caused anxiety for the resident as well as those who had committed to bringing her on board. Irby said one of the biggest challenges was commissioning a salary survey that helped satisfy the U.S. Department of Labor's requirement for the hospital to pay the resident the local prevailing wage.

Overall, she said, “the technicalities of the H-1B paperwork are so complex that you really need an expert to assist with the process.” For her resident, Irby received substantial help from the international office of Partners HealthCare, the hospital’s parent organization.

Irby is open to considering H1-B sponsorship for other residency candidates, but she said they would need to be “superstars” to merit such a commitment.

Corinne Chahine-Chakhtoura, director of pharmacy clinical services and residency programs at 240-bed Saint Michael’s Medical Center in Newark, New Jersey, went through the visa-application process herself about a decade ago. Chahine-Chakhtoura started her pharmacy training at LAU but finished her studies in New York.

“When I came I was on an F-1 visa, I was a student. And when I started my work, there was no big deal. In 10 days, I was able to switch from an F-1 to an H-1B and be sponsored by my institution,” she said.

Since then, she has helped the medical center sponsor two pharmacy residents from LAU but found that the process has slowed considerably, mostly due to issues with the salary survey.

“The first time, it took us almost five months to get the paperwork done. And our resident did not start until September of that year instead of July,” Chahine-Chakhtoura said. She said the law firm that represents the hospital directed the visa-application process.

The next time, “even though we did everything to the T, we could not get that resident started until August,” she said.

She said the program’s preceptors had to devote extra time to the late-starting residents because their training lagged behind that of the residents who had been working since July. The residency year also had to be extended to accommodate the late start. Although both LAU-educated pharmacists performed very well, the extended residency year was disruptive enough to the program that it will no longer consider applicants who need an H-1B visa.

Chahine-Chakhtoura said she has successfully brought Canadian nationals into the residency program, and she is very willing to consider residents who have an F-1 visa and want to use their OPT year to complete a residency.

The really hard way. For non-U.S. pharmacists who were educated abroad at a school not recognized by ACPE, obtaining a residency position is particularly difficult.

“The first barrier is licensure. You have to be eligible for licensure to be in the Match,” Katz said.

One prerequisite to licensure is obtaining Foreign Pharmacy Graduate Examination Committee certification through the National Association of Boards of Pharmacy (NABP). This process involves verification of school records and, for nonnative English speakers, meeting NABP’s requirements on the Test of English as a Foreign Language.

In addition, according to NABP, most states require pharmacists to complete at least 1500 internship hours before taking the North American Pharmacist Licensure Examination. Katz said obtaining a visa to come to the United States for internship training is another hurdle for foreign-educated pharmacists.

In some cases, he has advised foreign-educated pharmacists to pursue a Pharm.D. degree from a U.S. pharmacy school, perhaps through an expedited program. After graduation, the person would be eligible for licensure and find it easier to complete a pharmacy residency.

Katz also recommended that foreign-educated pharmacists focus their residency search on large universities, like his, that have an international office.

“Outside of a university-type program, what I tell folks is look at larger hospitals, certainly teaching hospitals, and particularly teaching hospitals who have experience with foreign medical graduates,” Katz said.