A new cross-sectional study published in JAMA Network Open examines how heavily US primary care training programs rely on international medical graduates who are not citizens of the United States and explores what could happen if restrictions on H-1B visas disrupt that workforce pathway. The analysis focuses on differences among medical specialties and states, highlighting the geographic and institutional concentration of physicians whose training and immigration status may be closely linked to the future supply of primary care doctors.
International medical graduates, commonly referred to as IMGs, are physicians who obtained their medical degrees outside the United States or Canada. Many enter the US health care system through graduate medical education programs, including residencies and fellowships. These physicians may train under several immigration categories, but the H-1B visa is particularly important because it allows foreign professionals in specialty occupations to work in the United States. For physicians, the visa can support clinical employment after medical school and during residency or fellowship, although obtaining it involves regulatory, licensing, and employer requirements.
The study evaluates reliance on non-US IMGs across primary care training. In the US, primary care includes fields such as family medicine, internal medicine, and pediatrics, specialties that form the foundation of outpatient care, preventive medicine, chronic disease management, and first-contact services. Training programs in these fields are distributed across a wide range of hospitals and health systems, from major academic centers to community-based institutions. Their staffing patterns can therefore vary considerably by location, local workforce shortages, and the ability of hospitals to recruit physicians from abroad.
A cross-sectional design provides a snapshot of this system at a particular point in time. Rather than following individual physicians over many years, researchers compare existing patterns across specialties and states. This approach can reveal where non-US IMGs are most concentrated and which areas may be most exposed to changes in immigration policy. It can also identify potential vulnerabilities in the physician-training pipeline before those vulnerabilities become visible as reductions in clinic capacity, fewer residency positions, or longer waits for primary care appointments.
The analysis is especially relevant because residency training is a critical transition between medical school and independent practice. Physicians who complete residency in the United States often continue working in the country, including in regions with limited access to care. If a visa policy prevents qualified international graduates from entering training or moving into subsequent clinical positions, the effects could extend beyond individual hospitals. Fewer trainees may eventually translate into fewer practicing physicians, particularly in communities that already struggle to attract and retain primary care providers.
H-1B restrictions could affect this pathway through several mechanisms. A physician may require an H-1B visa to begin or continue employment, while a hospital or medical group must act as the sponsoring employer. Limits on eligibility, delays in processing, employment transitions, or changes in the rules governing visa availability could make recruitment more difficult. The practical effect would not necessarily be uniform: programs with a large domestic applicant pool might absorb disruptions more easily, whereas institutions that depend heavily on non-US IMGs could face immediate challenges filling training positions.
The researchers’ specialty- and state-level approach is designed to capture that uneven exposure. A national average can conceal important regional differences, because reliance on international graduates may be concentrated in particular states or in specific types of programs. Rural hospitals, safety-net institutions, and health systems serving medically underserved populations may have different recruitment resources from large metropolitan academic centers. Mapping the distribution of non-US IMGs in primary care training can therefore help policymakers and health administrators distinguish broad national trends from highly localized risks.
The study does not establish that every physician training under an international visa would be unable to continue working if H-1B restrictions changed. Immigration pathways can involve multiple visa categories, and individual outcomes depend on factors such as citizenship, prior status, employer sponsorship, licensing, and eligibility for alternative programs. Instead, the investigation estimates the potential scale of disruption by identifying how much primary care training relies on physicians whose participation may be affected by H-1B policy. That distinction is important when interpreting the findings: the analysis describes exposure to policy change, not a guaranteed number of physicians who would leave the system.
The implications reach beyond immigration policy. Primary care shortages are shaped by compensation, geographic distribution, working conditions, training capacity, and the availability of support staff, among other factors. Visa restrictions would represent one additional pressure on a system already attempting to expand access to preventive and longitudinal care. The study’s findings may help residency programs, health systems, professional organizations, and government agencies evaluate contingency plans, improve workforce forecasting, and consider how immigration rules interact with medical education. The investigation is accompanied by a commentary in JAMA Network Open, underscoring the broader debate over how the United States can sustain a stable and geographically balanced primary care workforce.
Subject of Research: Reliance on non-US international medical graduates in US primary care training and the potential effect of H-1B visa restrictions.
Web References: https://doi.org/10.1001/jamanetworkopen.2026.29274; accompanying commentary: https://doi.org/10.1001/jamanetworkopen.2026.29635
References: Karamitros G et al. JAMA Network Open. DOI: 10.1001/jamanetworkopen.2026.29274.
Keywords: International medical graduates, primary care, medical education, graduate medical education, H-1B visa, physician workforce, health care access, state-level health policy, residency training, United States.
