key: cord-307013-80dup4sr authors: Lu, Victor M.; Menendez, Ingrid; Levi, Allan D.; Komotar, Ricardo J. title: Letter to the Editor: Lessons to Learn from the Coronavirus Disease 2019 (COVID-19) Pandemic for International Medical Graduate Applicants and United States Neurosurgery Residency Programs date: 2020-08-24 journal: World Neurosurg DOI: 10.1016/j.wneu.2020.06.202 sha: doc_id: 307013 cord_uid: 80dup4sr nan T he opportunity to participate in a neurosurgery residency program within the United States is highly sought after by both American and international medical graduates (IMGs). Estimates suggest 6%e8% of all residents in U.S. neurosurgery residency programs are indeed IMGs, 1,2 typically supported by either a J-1 (exchange) or H1-B (work) visa. In light of the current COVID-19 pandemic, a number of changes affecting the visa process in the United States has revealed particular immigration policies that are subject to change without notice. Sudden changes can affect when an incoming IMG resident can expect to start and therefore when a U.S. neurosurgery program can expect to have its full complement of residents. We highlight herein the key lessons learned from the current pandemic for potential IMG neurosurgery applicants and programs to consider. These will ensure both applicants and programs are better equipped to withstand any sudden changes to immigration conditions in the future. 1. Applicants should plan to be in the United States before Match Day. In the early stages of the COVID-19 pandemic, multiple countries, including the United States, installed travel bans both in and out of the country. The number of possible flights to the United States decreased, including from Lebanon 3 and India, 4 the 2 largest contributors of IMG residents to U.S. neurosurgery programs. 2 In this scenario, all successful IMG applicants would not have been able to physically reach their program were they not in the United States before these changes, impacting their application for various licenses and completion of scheduled orientations needed to legally commence residency. Therefore, being present in the United States before Match Day is recommended to ensure that if an IMG candidate is successful, changes in travel policies and plans will not impact their ability to start residency on time. 2. Programs should not solely rely on premium processing for H1-B visas. As lockdowns in the United States began, the U.S. Citizenship and Immigration Services suspended premium processing of H1-B visas, 5 which would have greatly impacted incoming IMG residents. This is because the time between Match Day and the start of the residency program is typically 3 months, and the time for H1-B petitions preeCOVID-19 required 6 months on average to be approved. Premium processing was the sole avenue in which these petitions could have been approved within the 3-month turnaround, as it expedites the process. Yet, with the suspension of H1-B processing, incoming IMG residents and programs would have had no choice but to delay their start date for an uncertain period of time waiting for their H1-B to be approved. 3. Applicants and programs should always have immigration and visa support. The most recent presidential executive order 6 in response to COVID-19 suspended the entry of all J-1 and H1-B visa holders from overseas entirely until the end of 2020. Although this occurred in June 2020, if it had occurred earlier, then any new IMG resident residing outside the United States would not have been eligible to enter the United States until 2021, and perhaps even apply for visa support then. It is difficult for a lay person to interpret if neurosurgery would have satisfied the sole exception to this order that those "involved with the provision of medical care to individuals who have contracted COVID-19 and are currently hospitalized" would be allowed entry at the discretion of the customs officer. 6 This is why accessible and contemporary immigration and visa support is crucial for any incoming IMG resident and program to properly interpret these caveats. 4. Applicants and programs should start preparing as soon as possible. An inevitable consequence of this COVID-19 pandemic is the backlog of visa petitions that have accumulated in the time of lockdown. This will likely lead to longer processing times for months once all the executive orders are completed. If the order is extended further beyond into 2021, who is to say new incoming IMG residents will need to apply for visas even earlier to ensure maximum time is given for their visa support to be approved. Moving forward, the impact of the backlog could even last up until the time IMG neurosurgery residents need to renew their visas, as neither the J-1 nor H1-B lasts for 7 years. Early preparation will allow IMGs and programs the best chance to ensure any possible delays in processing do not impact the start or continuation of training for IMG residents. The current COVID-19 pandemic has shed light on how difficult the immigration process can be for prospective IMG applicants and U.S. neurosurgery programs, as well as how unpredictable it can be. Given both the short turnaround from Match Day to the start of residency, as well as the 7-year duration of neurosurgery residency, there are multiple considerations future IMG applicants, current IMG residents, and programs should prepare for to ensure that their application, training, and service are not compromised. Informed preparation will serve all involved well to be better equipped to withstand any sudden changes to immigration circumstances in the future, even after the pandemic has abated. The path to U.S. neurosurgical residency for foreign medical graduates: trends from a decade Geographic distribution of international medical graduate residents in U.S. neurosurgery training programs Citizens: Beirut International Airport Closure Embassy and Consulates in India. Status of Repatriation Flights to the United States USCIS Announces Temporary Suspension of Premium Processing for All I-129 and I-140 Petitions Due to the Coronavirus Pandemic Proclamation Suspending Entry of Aliens Who Present a Risk to the U.S. Labor Market Following the Coronavirus Outbreak Conflict of interest statement: The authors declare that the article content was composed in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.https://doi.org/10.1016/j.wneu.2020.06.202.