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I finish cardiology fellowship in 2015. So I started looking for jobs as i dont want to specialize any further. I am on H1b visa. I am having HELL of TIME finding invasive non-interventionist (diagnostic caths) jobs in any part of the country. No doubt there are some jobs out there (about 50-60 jobs on most websites); but most of them are in very small towns (population between 10000-50000). There are hardly any hospitals willing to hire a h1b visa seeking cardiologist. Anyone else here who is in the same boat? Are I looking at the wrong places for jobs?
 

Instatewaiter

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Sounds like your search is pretty broad. You could contact a headhunter to give you a hand.

I'm going to be honest, with the fall in PCI and the same number of interventional fellows coming out, there probably arent a ton of jobs to do just diagnostic caths. Add to the at H1b visa and you are in your situation.

I'd bet you'd have more luck if you looked for non-invasive jobs. Give that a try if you still can't find work in a few months.
 
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Yeah its hard to find a invasive non-interventional job these days.
I wonder how non-invasive cardiologists make 300-400K with just echo, nucs and inpt/out pts? are they able to generate enough RVUs?
 

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Yeah its hard to find a invasive non-interventional job these days.
I wonder how non-invasive cardiologists make 300-400K with just echo, nucs and inpt/out pts? are they able to generate enough RVUs?
As a non-cardiologist, I say good to this. If your pre-test probability is high enough that you think a cath is indicated, I have no idea why you would put the patient through the risk of the procedure knowing that if you find something you cant do anything about it.

I see so many outside hospital transfers for "needs therapeutic PCI," from some local guy who just does diagnostic caths. Two procedures, two arterial pokes, what a waste.
 

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As a non-cardiologist, I say good to this. If your pre-test probability is high enough that you think a cath is indicated, I have no idea why you would put the patient through the risk of the procedure knowing that if you find something you cant do anything about it.

I see so many outside hospital transfers for "needs therapeutic PCI," from some local guy who just does diagnostic caths. Two procedures, two arterial pokes, what a waste.
Not sure if many will agree with me here, but everyone with a positive functional study (like nuc or echo) who is found to have disease needs a pci..
 

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Not sure if many will agree with me here, but everyone with a positive functional study (like nuc or echo) who is found to have disease needs a pci..
I completely disagree. Perhaps, needs a cath may be right. There is no proven MACE benefit of PCI in stable CAD(excluding 3vd/LM). Interventionalist?
 
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IM2GI: Most hospitals where a diagnostic cath is performed, there is also an interventionist who is on call to perform PCIs. I wouldnt be doing a diagnostic angiogram at a place where there are no interventionists to perform PCI.
 

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IM2GI: Most hospitals where a diagnostic cath is performed, there is also an interventionist who is on call to perform PCIs. I wouldnt be doing a diagnostic angiogram at a place where there are no interventionists to perform PCI.
But (and this is a serious question), do you ensure that any time you (generic) do a diagnostic cath that there's an interventionalist available to deploy a stent during the same procedure? Because if not, that's not much different than the "transfer for stent" patient, other than saving the cost of the ambulance or helicopter.
 

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IM2GI: Most hospitals where a diagnostic cath is performed, there is also an interventionist who is on call to perform PCIs. I wouldnt be doing a diagnostic angiogram at a place where there are no interventionists to perform PCI.
That does not seem to be the standard of practice in the surrounding community. Even if you had a guy on call to come to the room, I doubt its instant, and you are prolonging the case just because you wanted to do procedures/make more money. No way I would consent to let someone do a cath on me if I knew they would not have the skills/experience to handle an expected finding. When consenting patients, do you tell them that if you find something they will need another cath? What is a typical percentage of clean caths vs. ones you need to refer for PCI? The secondary question being, if you are having a high percentage of clean caths, are you doing too many, given lack of identified mortality benefit?

To me, it seems like doing a colonoscopy, finding a polyp, and then pulling out and saying I need to send the patient to someone else to take it out. Are there complicated polyps and coronary anatomy that should be referred? Sure, but I think if you are going to be doing the procedure, you should be able to handle common, expected findings.
 
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Instatewaiter

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As a non-cardiologist, I say good to this. If your pre-test probability is high enough that you think a cath is indicated, I have no idea why you would put the patient through the risk of the procedure knowing that if you find something you cant do anything about it.

I see so many outside hospital transfers for "needs therapeutic PCI," from some local guy who just does diagnostic caths. Two procedures, two arterial pokes, what a waste.
Completely agree. Unfortunately we get sent these patients frequently.

Some places have a set up where they have a few interventionalists and more people doing diagnostics to funnel the interventions to the PCI guy. That seems like a reasonable setup. Having no PCI guy though, is a terrible set up.

That does not seem to be the standard of practice in the surrounding community. Even if you had a guy on call to come to the room, I doubt its instant, and you are prolonging the case just because you wanted to do procedures/make more money. No way I would consent to let someone do a cath on me if I knew they would not have the skills/experience to handle an expected finding.
Prolonging the case for 20 minutes isn't really that big of a deal. You're not really doing the procedure at that point. The patient is just laying there with a sheath in place for 20 minutes or so. It's not as if you're keeping a catheter in the LM waiting for the interventionalist to come in the room. And usually you'd have to switch out to a guide catheter anyway, so it's a trivial extra risk overall.
 

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Well, considering ad hoc PCI is more and more frowned upon, having a diagnostic only physician is not an unreasonable thing and definitely not a "waste". Doing an intervention in a coronary artery is a little more complex than removing a polyp at the time of a colonoscopy. From SCAI consensus statement:

"Ad hoc PCI has increased in prevalence over the past decade and is the default strategy for treating acute coronary syndromes. However, questions about its appropriateness for some patients with stable symptoms have been raised by the results of recent large trials comparing PCI to medical therapy or bypass surgery. Ad hoc PCI for stable ischemic heart disease requires preproce- dural planning, and reassessment after diagnostic angiography must be performed to ensure its appropriateness. Patients may prefer ad hoc PCI because it is convenient. Payers may prefer ad hoc PCI because it is cost-efficient. The majority of data confirm equivalent out- comes in ad hoc versus delayed PCI. However, there are some situations in which delayed PCI may be safer or yield better outcomes."
 

Instatewaiter

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Well, considering ad hoc PCI is more and more frowned upon, having a diagnostic only physician is not an unreasonable thing and definitely not a "waste". Doing an intervention in a coronary artery is a little more complex than removing a polyp at the time of a colonoscopy. From SCAI consensus statement:

"Ad hoc PCI has increased in prevalence over the past decade and is the default strategy for treating acute coronary syndromes. However, questions about its appropriateness for some patients with stable symptoms have been raised by the results of recent large trials comparing PCI to medical therapy or bypass surgery. Ad hoc PCI for stable ischemic heart disease requires preproce- dural planning, and reassessment after diagnostic angiography must be performed to ensure its appropriateness. Patients may prefer ad hoc PCI because it is convenient. Payers may prefer ad hoc PCI because it is cost-efficient. The majority of data confirm equivalent out- comes in ad hoc versus delayed PCI. However, there are some situations in which delayed PCI may be safer or yield better outcomes."
I've read that. It seems to be knee jerk to all the unneccssary stents that are being put in (Baltimore and Ohio come to mind). You shouldn't send your patient to a LHC +/- PCI if you don't have a plan on what you're going to do depending on what you find. A second arterial stick is an unneccessary risk that a little forethough can prevent. Ad hoc reduces costs, reduces risk and puts the patient only through one procedure.
 

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I've read that. It seems to be knee jerk to all the unneccssary stents that are being put in (Baltimore and Ohio come to mind). You shouldn't send your patient to a LHC +/- PCI if you don't have a plan on what you're going to do depending on what you find. A second arterial stick is an unneccessary risk that a little forethough can prevent. Ad hoc reduces costs, reduces risk and puts the patient only through one procedure.
One could argue that in a non-ACS setting, one should never perform PCI, as there is no benefit. In those cases no interventionalist would need to stand by.

p diddy
 

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One could argue that in a non-ACS setting, one should never perform PCI, as there is no benefit. In those cases no interventionalist would need to stand by.

p diddy

Mortality sure but not morbidity. Refractory angina is a pretty terrrible thing to have to deal with as a patient. '
 
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P Diddy

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No proven mortality benefit. Not no benefit. Right?
That's debatable. The data is not impressive for a morbidity benefit from PCI, particularly since 'need for urgent revascularization' is often the endpoint that drives the composite benefit. In texas/baltimore/cleveland having a femoral artery signifies a need for urgent revascularization.

In any case, with no mortality benefit for PCI, an initial trial of medical management is warranted in non-ACS situations, so no interventionalist need be present. The original point stands.

p diddy
 

Trifling Jester

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That's debatable. The data is not impressive for a morbidity benefit from PCI, particularly since 'need for urgent revascularization' is often the endpoint that drives the composite benefit. In texas/baltimore/cleveland having a femoral artery signifies a need for urgent revascularization.

In any case, with no mortality benefit for PCI, an initial trial of medical management is warranted in non-ACS situations, so no interventionalist need be present. The original point stands.

p diddy
I don't think an interventionalist needs to be on call at all times for all diagnostic caths. I also don't think that a noninvasive approach is always warranted for all non-ACS lesions. Each situation is different.
 

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a lot of these blanket statements about the benefits (0r lack of) of PCI will not be applicable in most situations without knownig things like symptoms, location of lesion, severity of lesion, ejection fraction etc. if only it was as simple as no mortality benefit = no PCI!!
 

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a lot of these blanket statements about the benefits (0r lack of) of PCI will not be applicable in most situations without knownig things like symptoms, location of lesion, severity of lesion, ejection fraction etc. if only it was as simple as no mortality benefit = no PCI!!
as the initial approach for someone without cardiogenic shock or STEMI, it is indeed that simple.

p diddy
 

Instatewaiter

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1. Mortality benefit? None. Medically manage and reassess.

2. CABG

p diddy
Frisc II- statistically significant death/MI, death and MI with invasive vs conservative in NSTEMI
Tactics-TIMI 18- statistically significant death/MI/repeat ACS at 6 mo in NSTEMI
Meta analysis from JACC 2007- statistically significant reduction in mortality and statistically significant reduction in repeat MI in NSTEMI
 

P Diddy

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Frisc II- statistically significant death/MI, death and MI with invasive vs conservative in NSTEMI
Tactics-TIMI 18- statistically significant death/MI/repeat ACS at 6 mo in NSTEMI
Meta analysis from JACC 2007- statistically significant reduction in mortality and statistically significant reduction in repeat MI in NSTEMI
Composite endpoints do not prove your point.* Neither do meta-analyses.

*If you read the FRISC II trial carefully, you will see the endpoint is not driven by mortality (p = .693), but by repeat MI. What are they teaching you in Cleveland?

Lancet. 2006 Sep 16;368(9540):998-1004.
5-year outcomes in the FRISC-II randomised trial of an invasive versus a non-invasive strategy in non-ST-elevation acute coronary syndrome: a follow-up study.
Lagerqvist B, Husted S, Kontny F, Ståhle E, Swahn E, Wallentin L; Fast Revascularisation during InStability in Coronary artery disease (FRISC-II) Investigators

p diddy
 

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We're way way off topic at this point, but anyway: I have come to peace with the fact that improvements in mortality are difficult to achieve in interventional cardiology. I don't think that is primarily what our job is about, STEMIs notwithstanding (and even then... how many times have you opened, e.g., a distal RCA or whatever, wall motion never really comes back despite a good DTB time and a technically good result, and you probably did not dramatically affect mortality or morbidity in that patient. This is not terribly infrequent.) Most of my interventional practice addresses patients who have symptomatically failed medical therapy and I'm purely attempting to address QOL. I have no problem with that.
 

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We're way way off topic at this point, but anyway: I have come to peace with the fact that improvements in mortality are difficult to achieve in interventional cardiology...Most of my interventional practice addresses patients who have symptomatically failed medical therapy and I'm purely attempting to address QOL. I have no problem with that.
That's how I use PCI for my patients. Great to see a sensible interventionalist out there.

p diddy
 

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We're way way off topic at this point, but anyway: I have come to peace with the fact that improvements in mortality are difficult to achieve in interventional cardiology. I don't think that is primarily what our job is about, STEMIs notwithstanding (and even then... how many times have you opened, e.g., a distal RCA or whatever, wall motion never really comes back despite a good DTB time and a technically good result, and you probably did not dramatically affect mortality or morbidity in that patient. This is not terribly infrequent.) Most of my interventional practice addresses patients who have symptomatically failed medical therapy and I'm purely attempting to address QOL. I have no problem with that.
None of this really addresses the question of why there are people in the community doing only diagnostic caths. If your one benefit is providing only symptomatic improval, is it worth two caths?
 

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None of this really addresses the question of why there are people in the community doing only diagnostic caths. If your one benefit is providing only symptomatic improval, is it worth two caths?
If every patient who gets a diagnostic cath eventually requires a PCI, then no. But what about 1 in 5? 1 in 10? Remember everyone in the COURAGE trial had a diagnostic angiogram.

Furthermore, you can do diagnostic caths for other reasons than determining the approach to angina, ascertaining the etiology of heart failure among them.

Finally, you do realize that all patients who undergo CABG have had an angiogram, right?

p diddy
 

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I respectfully disagree with the GI doctor who thinks that no non-interventionalist should do a diagnostic cath. I do diagnostic cath but not PCI/interventions. I work at 2 different hospitals- 1, academic/large hospital with interventionalists standing by to come and do PCI if something is found that needs PCI. 2nd hospital is a small 150 bed community hospital with a diagnostic-only cath lab. They don't have interventionalists, nor the stents and cath lab staff to do PCI/intervention at that hospital. However, I can do diagnostic caths there and occasionally do - some of the reasons would be if a patient does NOT want transfer to another hospital (not infrequent since some elderly patients really prefer to stay @This hospital in their community, and not go somewhere else unless no other option at all), or if patient is capitated and has to be treated at that hospital system and can't go to our university hospital. Also, if the patient has an abnormal nuclear study but that I think might be bogus/false positive, and is a low risk type case (not likely to be a difficult arterial access, etc.), then I am willing to do the case over there. I do NOT try high risk cased over there, in general (patient with a lot of peripheral arterial dz, etc.). In general I think it is a positive for patients - remember that nuclear studies/SPECT and even the newer, more accurate PET studies have a significant false +/false - rate and sometimes the dx of having CAD or not is still in doubt and for some patients a diagnostic cath can be a good thing to reach a diagnosis, to know what we are treating (CAD versus noncardiac chest pain), if the diagnosis is still in doubt despite noninvasive testing. I'm actually quite conservative, and in case anyone is curious, diagnostic cath actually pays pretty crappy so there's not much financial incentive to do an unnecessary one...not to mention the fact it would be unethical to do so and I wouldn't knowingly do so.
 

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with regard to the original post, the OP is probably going to need to go to some rural type area, and not a major urban area, with his/her visa issues. But I believe there will be jobs there. It might help to find a recruiter/head hunter. Part of his problem might be that he is not graduating for another year, and most of these jobs/help wanted posts are looking for someone from now - 6 months from now. They may be more interested in talking to him next year...
 
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I finish cardiology fellowship in 2015. So I started looking for jobs as i dont want to specialize any further. I am on H1b visa. I am having HELL of TIME finding invasive non-interventionist (diagnostic caths) jobs in any part of the country. No doubt there are some jobs out there (about 50-60 jobs on most websites); but most of them are in very small towns (population between 10000-50000). There are hardly any hospitals willing to hire a h1b visa seeking cardiologist. Anyone else here who is in the same boat? Are I looking at the wrong places for jobs?
You know- its these posts that I find hilarious. You've left your home country which probably badly needs doctors and are complaining about living in rural towns? I am currently located in an area less than 50k population. You should be thankful that you've been given this golden ticket out of wherever you've come from. At the very least you can do what you were supposed to do when you moved to the US- serve underpopulated regions.

I think its absurd that foreign doctors want to have the easy way out when their jobs are meant for regions that people in the US aren't willing to do.

If you're unhappy with your 50k population then perhaps you should consider your home country's larger cities? Not being disrespectful as I myself come from foreign background but lets keep it real here.
 

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You know- its these posts that I find hilarious. You've left your home country which probably badly needs doctors and are complaining about living in rural towns? I am currently located in an area less than 50k population. You should be thankful that you've been given this golden ticket out of wherever you've come from. At the very least you can do what you were supposed to do when you moved to the US- serve underpopulated regions.

I think its absurd that foreign doctors want to have the easy way out when their jobs are meant for regions that people in the US aren't willing to do.

If you're unhappy with your 50k population then perhaps you should consider your home country's larger cities? Not being disrespectful as I myself come from foreign background but lets keep it real here.
Try one of these 2 things - it will make you feel better: Either get off that high horse or choose a shorter pedestal to stand on. Just a suggestion.
 
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Try one of these 2 things - it will make you feel better: Either get off that high horse or choose a shorter pedestal to stand on. Just a suggestion.
How am I coming from a high pedestal. The OP was complaining about working in rural areas - his dissatisfaction apparently not tempered by the sheer opportunity to live and work in the US. OP was probably given the opportunity to work in the US because of a need for rural physicians. Thats the predominant reason why foreign doctors are given visas - not so they can live comfortably in large cities in SF. That he's not even willing to live in a rural town is absurd considering that he probalby left a country that is badly in need of doctors in the first place.

I understand we are all fortunate to be in the position of becoming doctors and its really luck of the draw who gets born where and what opportunities. I'm foreign born myself but raised in the US since I was a kid. None of my home country's tax money went into raising me nor any implicit assumption that my training was meant for said home country. I'm educated in the US and I plan to stay in small towns or relatively small towns near big cities but I sure as heck am not complaining about towns less than 50000 in size because it doesnt fit some absurd definition of comfort.

OP should be glad he's in the US over the thousands of foreign doctors who either do not get residency in the US or don't get visas in the first place. He comes across petulant and ignorant and blind to the circumstances.
 

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For what it's worth, I actually agree with sanj238. Preference should always be given to American trained physicians. But Im just a medical student so my opinion is prob not worth much here lol
 
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Sanj238: how did you conclude that I was given a visa because of a need for rural doctors in USA? The year I moved to the USA for residency about 4000 internal medicine residency spots were filled by international medical graduates because AMGs would not have been able to fill those spots. Being on H1b, I never had an obligation to work in a specific area (rural vs urban). I get to decide what my comfort level is and where i want to work. Does that hurt you?
I really dont understand what golden ticket you are talking about. Most americans I meet are thankful and appreciate the fact that i moved to the USA and i decided to provide my services to them. Who gives a golden ticket to anyone these days?
You assume people in "large cities like SF live comfortably". You assume I want to live in a big city in USA. You assume I do not want to live in a big city in my own country. You assume i was given a visa so that i could work in underserved area. You just assume things about people you have no idea about.
MIND YOUR OWN BUSINESS. Grow up. Nothing personal.
 
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Sanj238: how did you conclude that I was given a visa because of a need for rural doctors in USA? The year I moved to the USA for residency about 4000 internal medicine residency spots were filled by international medical graduates because AMGs would not have been able to fill those spots. Being on H1b, I never had an obligation to work in a specific area (rural vs urban). I get to decide what my comfort level is and where i want to work. Does that hurt you?
I really dont understand what golden ticket you are talking about. Most americans I meet are thankful and appreciate the fact that i moved to the USA and i decided to provide my services to them. Who gives a golden ticket to anyone these days?
You assume people in "large cities like SF live comfortably". You assume I want to live in a big city in USA. You assume I do not want to live in a big city in my own country. You assume i was given a visa so that i could work in underserved area. You just assume things about people you have no idea about.
MIND YOUR OWN BUSINESS. Grow up. Nothing personal.
You can ignore my comments all you wan't but I want this on the record for everyone else to see.

This is certainly my business as foreign doctors love avoiding becoming internists as much as possible though they are here for the implicit assumption to fill a significant shortage in primary care positions. Maybe you are offended thats your problem. But the reality is reality. You've also misinterpreted my comments- which of course is fine so I'll clarify.

I didn't say you wanted to live in SF- but for many a large city or moderate city is considered ideal. These are generalizations that fit the mean.

Whether there are 4000 or 5000 or whatever number IM spots being open has nothing to do with your current position. Are you going to be an internist as a trained IV cardiologist? Did you apply to the IM spot because there was an unfilled need for future internists or because open IM meant a ticket into subspecialization? Yours was merely an opportunistic choice to use IM as a stepping stone to something else. I'm pointing out the most likely reality here. How much you want to deny this is your problem. Please don't post useless stats about IM openings. You are not an IM doctor. Do tell me, how many unfilled IV training spots are there?

Oh no, you had no obligation at all because it was implied. Shall we pull out the documents that make a request for international medical graduates to fill rural and primary care? or did you miss that memo?

Of course you get to decide what your comfort level is. This is a free country. You came on this forum asking AMGs for advice to avoid what for you are undesirable locations. As a free person I was pointing out the wonderful irony of your own condescension towards the rural folk of this country when you've been fortunate enough to avoid a similar fate from your own home nation.

And yes you were given a visa- whether expliciitly said or not because there is a shortage of physicians far more serious in the primary care setting than any other field. And before you read between the lines and attempt to put me in a box- let me make this clear. I dont care what shortage there is for cardiologists- there is a far greater shortage for primary care.
 
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You can ignore my comments all you wan't but I want this on the record for everyone else to see.

This is certainly my business as foreign doctors love avoiding becoming internists as much as possible though they are here for the implicit assumption to fill a significant shortage in primary care positions. Maybe you are offended thats your problem. But the reality is reality. You've also misinterpreted my comments- which of course is fine so I'll clarify.

I didn't say you wanted to live in SF- but for many a large city or moderate city is considered ideal. These are generalizations that fit the mean.

Whether there are 4000 or 5000 or whatever number IM spots being open has nothing to do with your current position. Are you going to be an internist as a trained IV cardiologist? Did you apply to the IM spot because there was an unfilled need for future internists or because open IM meant a ticket into subspecialization? Yours was merely an opportunistic choice to use IM as a stepping stone to something else. I'm pointing out the most likely reality here. How much you want to deny this is your problem. Please don't post useless stats about IM openings. You are not an IM doctor. Do tell me, how many unfilled IV training spots are there?

Oh no, you had no obligation at all because it was implied. Shall we pull out the documents that make a request for international medical graduates to fill rural and primary care? or did you miss that memo?

Of course you get to decide what your comfort level is. This is a free country. You came on this forum asking AMGs for advice to avoid what for you are undesirable locations. As a free person I was pointing out the wonderful irony of your own condescension towards the rural folk of this country when you've been fortunate enough to avoid a similar fate from your own home nation.

And yes you were given a visa- whether expliciitly said or not because there is a shortage of physicians far more serious in the primary care setting than any other field. And before you read between the lines and attempt to put me in a box- let me make this clear. I dont care what shortage there is for cardiologists- there is a far greater shortage for primary care.
I hate to argue with you anymore. You just dont have your facts right and you keep uttering complete non-sense.
A few pointers- you said foreign doctors avoid becoming general internists? Just look around...
I say it again there is no compulsion for an IMG on H1B to work in an underserved area. Period.
You could assume whatever you want in your fantasy world- foreign docs come to USA to work in rural areas or mexicans come to work in meat plants.
Btw why do you assume this forum is used by AMGs only? Please do not make this a AMG vs IMG thing.
You worry a lot about my home country.
The irony is - You need to worry about YOUR home country, where foreign doctors are needed to serve the rural countryside as YOUR countrymen chose not to work there and chose to live in "ideal comfortable cities like SF''? Please lecture your own countrymen first before lecturing me.
Please dont waste everybody's time here.
 
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