After Residency (or Fellowship)

In medicine, the saying experience is the best teacher has likely

been ingrained in our brain; which is mostly true in our learning
process. Nothing teaches us better about a disease than managing a
patient with that particular disease. However, I believe that there are
some things that we do not need to learn by experiencing it ourselves;
and instead, we can learn from someone elses. Deciding what to do
after residency (or fellowship) as an IMG on J1 visa is one of them.
For what its worth, Ive learned a lot about this by experiencing what
seems to be unfortunate chain of events, which I hope you wont have
to go through; hence this post If you dont want to know the
background story, skip to So what are the options?
A little background story
I was not able to get H1B visa for residency because my Step 3 score
release got delayed. Did I regret doing residency on J1? No, because J1
made it possible for me to transfer to another program (which is a
more recognized one) during my residency training to be together with
my family again, and it opens more doors for fellowship. Fellowship
was something I really wanted to pursue, and I would most likely not
be able to do it on H1B. There are less and less fellowship programs
that accept H1B.
During first year of fellowship, I contemplated about waiver job. But a
waiver job for my subspecialty was (and still is) quite rare, so I would
have to be ready to work as a primary care provider in a (usually) nonacademic setting. Dont get me wrong! I love my specialty, thats why I
chose this field. But my passion is in my subspecialty and medical
education. Another thing about a waiver job is that you cant be picky
about geographic location since most waiver jobs are available in
underserved or rural areas. That would be a serious problem for my
husband as his career thrives in large research-based universities, so
we might have to live apart for 3 years of waiver job, anyway In
addition, we already had a daughter whose education has always been
one of our priorities, and we believe underserved or rural areas are not
in her best interest. The last straw came 3 months before my 1st year
of fellowship ended, though. My father in Indonesia had a hemorrhagic

stroke. By Allahs grace, he has done really well since. But that was
when I made the decision to just go back to Indonesia for 2 years
following completion of my fellowship. My husband was still uncertain
about where he wanted to establish his career, so I did not know
whether we would go back to our Indonesia for good someday. One
thing we realized, my parents wouldnt be getting younger, and we
couldnt tell if another chance of spending 2 years with them would
ever come to me again. So I made the decision: Id do my 2-year home
country physical residence requirement while my husband would stay
in the US to start building his career.
At the beginning of my third year, however, I heard that a J1 fellow in
the same subspecialty from another program was able to get a waiver
job as a subspecialist in an academic setting! Well, that set the wheels
in my head in motion. I discussed it with my husband and parents, who
supported my thought about looking for a waiver job in the US. I got
several places that were interested in hiring me, but there were 2 that
were really serious; both were academic institutions. The first one
didnt work because the job would require me to be licensed in 2
states, which cannot be done for J1 waiver. The second one progressed
slowly but looked promising. Thankfully I could stay in the US up to 6
months after completion of my fellowship for subspecialty board exam.
By September, I got an official offer from the second place as a
subspecialist. So my plan was to go back to Indonesia after board
exam and return to the US once my waiver papers and therefore H1B
were all set. Maybe 3-4 months
Only it didnt happen that way 2013 was the year where a lot of
federal funding cuts occurred. Given that places offering J1 waiver are
usually fully or partially dependent on federal funding, the place that
offered me the job had to retract their offer because of the cut, 3.5
weeks before my flight. So now I had to stay in Indonesia for 2 years. I
think the fatal mistake I committed was not continuing to find a
position in Indonesia when I looked for J1 waiver job in the US.
The first few months in Indonesia were not too hard on me career-wise
because my baby son just turned 9 months when we arrived in
Indonesia. So I spent my time taking care of him. It was very hard
relationship-wise because my husband & I decided to have our then 7-

year old daughter stay with my husband in the US for those 2 years. It
is getting better now. Skype is our lifeline!
Anyway, I started looking for a position as soon as I arrived in
Indonesia. I looked for non-clinical positions since I didnt (and still
dont) want to do adaptation program, especially in teaching or maybe
infection control. But it was not easy. Most medical schools, especially
private ones, want teachers who can also do clinical service. Infection
control committees, at least at a place I tried applying to, also want
people who also do clinical service (I found this to be counter-intuitive
since I believe that they can benefit more from having someone
working full-time in infection control and antimicrobial stewardship
without the added responsibilities of clinical service But this
argument is beyond the scope of this post). Of medical schools that
were open to my being a faculty member without providing clinical
service, including in medical education units, there was another issue:
their status as public universities and therefore the horrendous
bureaucracy of hiring a faculty member who is not a civil servant. One
thing that really put me off is that some places offered to let me work
there as teaching staff as a volunteer, which I think is very
unprofessional. I support volunteer works, I do some myself, but your
professional job should not be a volunteer one. You may differ in your
opinion in this issue, but I see this offer as lack of respect to
colleagues, especially the relatively younger ones.
I also tried applying to more public-health-oriented positions with
international non-governmental agencies and even contemplated
bench research of which experience I gained during fellowship, but I
fully realized that my expertise and passion are not in those areas and
we may not be the best fit for each other.
I have to admit it was depressing to not be able to work in your home
country, in the fields that you are really passionate about, after
spending 6 years of training in the US. And its not that I didnt try to
talk to the right people; my husband and I contacted & met several
higher-ups, including those in charge of medical council and adaptation
program. I went to interviews with 5 medical schools before I finally got
a position in medical education unit of a highly-regarded private
medical school, and I have been very happy. My current workplace is
very understanding about the possibility of my returning to the US and

very receptive about how I can continue to contribute something even

if I return to the US in the forms of guest lecture or networking for their
medical students and faculty. However, it took me 10 months before I
got the job. Do I regret my Indonesia stay so far? No, because I now
spend time with my parents and siblings. What I regret is not preparing
this stay better. So what would I suggest to you?
What are the options?
1.

2.

3.

4.

Waiver after residency

If youve never been interested in subspecialty and have no
intention to go back to Indonesia, this is your path. Start
looking for a waiver job in mid second year of residency. Waiver
process will not start until you sign a contract, so search early.
This can also be done even if youre interested in pursuing
subspecialty. The caveat, however, make sure your waiver job
experiences add value to your application to fellowship
programs. Sometimes sometimes I wonder if things would be
different for me if I chose this path.
Waiver after fellowship
If you really want to pursue subspecialty right after residency
(because the chance to get accepted is usually bigger), but you
have no intention to go back to Indonesia, you can still try to
look for a waiver to do after fellowship. You can look for waiver
jobs in primary care or in your subspecialty; just be aware that
waiver jobs as subspecialists are only available in a few
subspecialties.
Same thing, search early! Remember, keep preparing for plan B
back in Indonesia. Dont do the same mistake I did!
Working in medical education field in Indonesia
I think this is the field that is most open to foreign-trained
specialists if you decide to go back to Indonesia, especially if
your training has been in developed countries with wellestablished medical education system. People in this field
appreciate your experience in learning and teaching you have
gained in residency/fellowship.
Start contacting medical schools approximately 6 months
before graduation. Dont start late like I did! Private medical
schools or new public medical schools are more receptive.
Working in bench research in Indonesia

5.

6.

I dont know much about how open this field is for us, but the
people in this field will definitely welcome you if you bring
funding with you. So if your interest is in it, my advice is to try
getting a grant that you can bring with you to Indonesia during
residency or fellowship. Easier said than done, I know. Or, prove
that youre a star scientist by your publications in areas wellrecognized in Indonesia; preferably at the institution(s) you
intend to apply to, such as Eijkman Institute or Biofarma.
Working in public-health related projects with non
governmental agencies in Indonesia
If public health is your interest, try to get an additional degree
with your residency/fellowship. For example, some fellowship
programs offer the opportunity to pursue MPH. Or, do an
elective with an international non-governmental agency in a
public health related project in a developing country.
Completing adaptation program to be able to work as a
clinician in Indonesia
If you want to go back to work in Indonesia, this is your option,
at least until end of 2015. After that well see if the
regulations change. Adaptation programs vary a lot in waiting
time, length of the program, learning atmosphere, tuition &
other fees, etc even in the same specialty. One thing for
sure, it is time-, mind-, and money-consuming. Oh, and the
papers! So prepare yourself! I have no experience with it to be
able to explain the process, but if you google it, there are a few
blogs doing exactly that.

Thats all for now. If you still have questions, please email me or send
me a message. Hope it helps a little.
NIH Jakarta, January 2015