To understand the argument, it helps to revisit what Abraham Flexner actually did. Commissioned by the Carnegie Foundation, Flexner toured medical schools across the United States and Canada and delivered a devastating assessment of a profession with weak oversight, inconsistent curricula, and thin scientific grounding. His remedy was sweeping: standardized curricula and assessment, formal university affiliation, faculty scholarship, laboratory training, and a curriculum anchored in basic science and clinical application. Drawing on German models that emphasized research and formal instruction, Flexner sought to make physicians better prepared and patients safer. By those measures, the report succeeded spectacularly, and it established the organizing principles that still govern medical education today.

But the reforms carried a hidden price. Consolidating training within well-resourced academic institutions forced the closure of schools that could not meet the new standards, and the burden fell unevenly. Of the seven historically Black medical schools operating in 1910, five closed, leaving only Howard University and Meharry Medical College. These institutions had been chronically underfunded, excluded from major teaching hospitals, and largely ignored by donors, making them acutely vulnerable to standards they had no resources to meet. Flexner himself held views that reflected the racial attitudes of his era, suggesting that Black physicians should focus on basic care and disease prevention in Black communities rather than full professional equality, a stance that influenced which schools survived.

Women in medicine faced a parallel contraction. Flexner acknowledged that women were formally admitted to most schools but attributed their low enrollment to declining interest rather than structural barriers, and he suggested their aptitude was best suited to fields such as maternal and child health. The closure of women’s medical schools and their consolidation into male-dominated institutions reduced pathways for women physicians and contributed to a prolonged decline in women’s representation across much of the twentieth century. Together, the authors write, these reforms contracted access to medicine for Black individuals and women by a full generation, and surgical education, concentrated ever more tightly within elite academic centers, amplified the exclusion.

The demographic echoes are measurable today. According to data cited in the analysis, Black individuals made up 11.6 percent of the U.S. population in 1900 but only 1.3 percent of physicians; by 1940 the figures were 9.7 percent and 2.8 percent. Currently, Black Americans represent roughly 13.4 percent of the population but only 7.8 percent of general surgery residents, while women account for just 37.9 percent of general surgery residents according to recent Association of American Medical Colleges data. Women comprise approximately 39 percent of fellowship trainees after general surgery residency, a pattern the authors link to persistent attrition discrepancies across the surgical training continuum. Of the four Historically Black Colleges and Universities with affiliated accredited medical schools today, only Howard University and Morehouse School of Medicine operate surgical residency programs, yet HBCUs continue to produce a disproportionately high share of Black physicians, faculty, and academic leaders.

Federal policy has repeatedly tried to repair the damage. Title VII programs, Medicare Graduate Medical Education funding, and affirmative action policies aimed to expand opportunity and address historical inequities. The physician shortage that Flexner-era consolidation helped create was partly offset by the Immigration and Nationality Act of 1965, which opened the door to international medical graduates who became essential to primary care, rural, and safety-net settings. That reliance, however, carries global costs, including the migration of highly trained professionals away from low-resource countries, a phenomenon known as brain drain, along with ongoing workforce inequities for international graduates themselves. The authors argue that the United States built a health system dependent on physicians trained abroad while constructing an immigration environment that keeps their presence perpetually uncertain, a structural inequity deserving the same scrutiny as domestic disparities.

The paper also sounds a contemporary warning. Executive orders issued in 2025, including Orders 14,148, 14,151, and 14,173, revoked workforce guidance for underrepresented groups, paused or rescinded diversity initiatives, and removed race- and gender-based preferences in federal programs. The authors draw a direct line between these actions and Flexner’s reforms: both were presented as neutral and merit-based, yet both risk ignoring unequal starting points and structural barriers that continue to shape outcomes. The lesson, they contend, is that reforms can pursue excellence and still cause harm when they ignore equity, and that good intentions alone are insufficient.

Against this historical backdrop, the analysis examines the machinery of modern evaluation. The Liaison Committee on Medical Education, established in 1942, and the Accreditation Council for Graduate Medical Education now serve as central levers for fairness in training. Although the LCME does not explicitly frame its standards around bias, requirements such as ED-21 and ED-23 mandate education in cultural competence and health disparities, while ED-30, ED-33, and ED-46 emphasize fair assessment and continuous quality improvement, and IS-23 supports holistic admissions. At the residency level, the Clinical Competency Committee, introduced by the ACGME in 2013 alongside the Next Accreditation System and the Milestones Project, replaced informal, program-director-driven assessment with structured, committee-based review of multiple data sources. That group-based deliberation protects individual trainees by reducing reliance on single evaluators and minimizing biased decision-making, and it can surface microaggressions that individual evaluations miss. The Program Evaluation Committee performs the analogous function at the program level, replacing episodic inspection with continuous, data-driven oversight of trainee satisfaction, patient outcomes, and recruitment.

Institutional culture, the authors stress, follows from leadership. They point to Washington University School of Medicine in St. Louis, which through formal anti-racism commitments, health equity curricula, and an Executive Faculty Task Force reported an 82 percent increase in underrepresented faculty and a 46 percent increase in female faculty, evidence that change requires structural investment rather than individual goodwill. Looking forward, the paper proposes evaluation frameworks that extend beyond operative volumes, milestone progression, and board pass rates to measure culture, belonging, mentorship, retention, empowerment, and leadership advancement, pairing quantitative metrics with focus groups, interviews, 360-degree evaluations, and climate surveys. Pathway programs such as Tulane’s IMPRESS and the University of Alabama at Birmingham’s PRISM and SURE initiatives have reported strong outcomes, with more than 93 percent of participants showing increased understanding of healthcare careers and 93 percent describing an enhanced sense of belonging in medicine. Federal agencies including HRSA, the National Institute on Minority Health and Health Disparities, and ARPA-H are increasingly funding such efforts, signaling a policy shift toward investing in human capital as a driver of both equity and excellence.

The ultimate message of the analysis is that excellence is neither static nor value neutral. Flexner established the importance of standards and accountability, yet his legacy demonstrates how reforms that ignore structural inequities can produce lasting harm. Contemporary accreditation, evaluation, and policy frameworks, the authors argue, offer an opportunity to reconcile those lessons by aligning educational quality with inclusion and social responsibility. Only by integrating historical awareness with equity-centered evaluation, they conclude, can the profession sustain a highly skilled and diverse surgical workforce capable of meeting the needs of the patients and societies it serves.

Subject of Research: Historical and equity-informed evaluation of surgical education programs from the Flexner era to modern accreditation policy

Article Title: Program evaluation and policy implications in surgical education: from flexner to the modern pursuit of access and excellence

Article References: Luo, X., Holmes, C., Pai, J., Rhodes, C., Bain, A., Paramesh, A., & Turner, J. (2026). Program evaluation and policy implications in surgical education: from flexner to the modern pursuit of access and excellence. Global Surgical Education – Journal of the Association for Surgical Education, 5(1), Article 141. https://doi.org/10.1007/s44186-026-00546-y

Image Credits: AI Generated

DOI: 10.1007/s44186-026-00546-y

Keywords: Flexner Report, surgical education, medical education, health equity, workforce diversity, ACGME, LCME, program evaluation, international medical graduates, residency training, holistic admissions, pathway programs

The findings, led by Neil S. Zhang and Atif Qasim of the University of California, San Francisco, along with collaborators at Creighton University and the Kirk Kerkorian School of Medicine at UNLV, are striking in their clarity. Overall, 32,091 of the 38,179 applicants, or 84.1 percent, successfully entered the subspecialty to which they applied. But that aggregate success rate conceals dramatic differences among applicant groups. Research productivity emerged as the single most powerful predictor: applicants with 11 or more publications had 4.18 times higher odds of success compared with those who had none, a stronger association than any other characteristic examined.

The study leveraged a unique combination of databases. Applicant characteristics came from the Electronic Residency Application Service, or ERAS, administered by the Association of American Medical Colleges, and were linked to the AAMC’s Graduate Medical Education Track, a national registry of trainees at every residency and fellowship program. An applicant was defined as successful if he or she appeared in GME Track as a fellow in the same subspecialty during the corresponding appointment year. The researchers excluded applicants who applied to more than one subspecialty, applied in multiple years, or had masked ages, yielding a cohort of single-time applicants to cardiovascular disease, endocrinology, gastroenterology, hematology and oncology, infectious disease, pulmonary and critical care medicine, nephrology, and rheumatology.

Statistically, the team used multivariable logistic regression to isolate the effect of each characteristic while adjusting for all others, along with the subspecialty and application year. Predictive margins were estimated to calculate adjusted probabilities of success for different applicant groups across publication categories. The cohort had a median age of 31 years, and 41.2 percent were female, 9.5 percent identified as underrepresented in medicine, and 39.6 percent were international medical graduates. Chief resident status, additional graduate degrees such as a PhD or master’s degree, and training in larger residency programs with 55 or more residents all independently boosted the odds of success.

Against these advantages, several groups faced measurable headwinds. Each additional year of age was associated with lower odds of success. After adjustment, female applicants had 0.89 times the odds of success, underrepresented-in-medicine applicants 0.84 times, osteopathic DO graduates 0.53 times, and international medical graduates just 0.44 times the odds of their counterparts. Graduates of community-based residency programs and community-based, university-affiliated programs were likewise significantly less likely to succeed than those from university-based programs, a pattern the authors attribute in part to the weight program directors place on the perceived reputation of the training institution.

The subspecialty-level breakdown sharpened the picture. The disadvantage for female applicants was most pronounced in cardiovascular disease and gastroenterology, where women had 0.79 times the odds of success, while the penalty for underrepresented-in-medicine applicants was especially evident in pulmonary and critical care medicine, at 0.59 times the odds. The payoff for research output also varied: the association between 11 or more publications and success was particularly strong in gastroenterology, pulmonary and critical care medicine, and endocrinology, though notably absent in infectious disease. Analyses restricted to the four most competitive subspecialties suggested that many of these disadvantages grew even larger in the toughest markets.

One of the most consequential findings concerns whether publications can compensate for baseline disadvantage. Predictive margins showed that success rose with publication count for every applicant group. For underrepresented-in-medicine applicants, the gap with non-underrepresented peers appeared to narrow at higher publication counts, although interaction testing did not reach statistical significance, likely because few such applicants reached the highest publication category. More sobering was the finding that the disadvantages experienced by female and DO applicants persisted at every level of research productivity, showing no attenuation whatsoever. International medical graduates gained more from each additional publication than their MD counterparts, yet even this larger benefit failed to erase their baseline gap entirely.

The authors frame these results as evidence of a self-reinforcing research arms race. Program director surveys consistently rank research involvement and perceived interest in scholarship among the most important selection factors, prompting applicants to accumulate ever more publications, which in turn pushes programs to value the metric even more. Prior work suggests many of these entries are never cited, raising concerns about the quality of the science behind the numbers. The ERAS publications variable aggregates journal articles, abstracts, book chapters, and presentations into a single count, so a first-author paper in a major journal currently carries the same statistical weight as a poster at a regional meeting, a limitation the researchers say should be addressed in future studies.

As a remedy, the study advocates for Mission-aligned Selection, a framework promoted by the AAMC that emphasizes individualized, systematic review of applicants’ experiences, attributes, and academic metrics in light of each program’s mission. Early adopters offer encouraging signals: after one pulmonary and critical care fellowship implemented holistic review practices, its faculty ranked publications among the least important metrics, and a pediatric surgery fellowship reported that the caliber of its interviewees actually improved. The authors also point to preference signaling, now available in several internal medicine subspecialties, as a tool that may reduce defensive over-application, though its effects on equity remain unproven. They caution that qualitative materials central to holistic review, such as letters of recommendation, have been shown to contain biased language toward female and underrepresented applicants, so standardization efforts must accompany any shift away from raw publication counts.

The study’s limitations are worth noting. Because direct match data were not available, success was defined as entering the subspecialty rather than formally matching, though out-of-match placements likely represent a small minority. Factors such as board scores, honors, interview ratings, and personal statements were unavailable, leaving room for residual confounding. Still, as the first comprehensive, individual-level national analysis of its kind, the work makes the structure of the fellowship selection process unusually visible. Its message is twofold: research output overwhelmingly determines who gets in, and the system as currently constituted systematically favors younger, male, non-underrepresented, US MD graduates at large university programs. Whether programs and their governing bodies embrace mission-aligned processes may determine not only individual careers but also the future diversity and representativeness of the internal medicine subspecialty workforce.

Subject of Research: Factors associated with successful entry into internal medicine subspecialty fellowships

Article Title: Characteristics and Success of Internal Medicine Applicants to Subspecialty Fellowships

Article References: Zhang, N. S., Tun, K. M., Batra, K., Babik, J. M., Huppert, L., Singh, A., Wahi-Gururaj, S., & Qasim, A. (2026). Characteristics and Success of Internal Medicine Applicants to Subspecialty Fellowships. Journal of General Internal Medicine. https://doi.org/10.1007/s11606-026-10688-w

Image Credits: AI Generated

DOI: 10.1007/s11606-026-10688-w

Keywords: internal medicine, fellowship match, graduate medical education, publications, underrepresented in medicine, international medical graduates, osteopathic medicine, mission-aligned selection, ERAS, cardiology, pulmonary critical care, workforce diversity

The stakes are not abstract. The Centers for Disease Control and Prevention place mental health among the nation’s central public health challenges, estimating that more than one in five American adults lives with a mental illness in any given year. The Association of American Medical Colleges has repeatedly warned that its workforce projection models point to deep physician deficits, with mental health specialties among the hardest hit. The National Resident Matching Program described the 2025 Main Residency Match as the largest in history, yet competition for psychiatric training positions remains fierce and unfilled slots persist in the very communities that need psychiatrists most. International medical graduates, or IMGs, are not a marginal labor pool waiting on the sidelines. A 2022 analysis in Academic Psychiatry examined the role of IMGs in the United States psychiatry workforce, and a study published a quarter-century ago in the American Journal of Psychiatry found that internationally trained psychiatrists already displayed distinctive practice patterns, including disproportionate service in the public sector. During the COVID-19 pandemic, a study in JAMA Network Open documented deaths among IMG physicians in the United States — a grim measure of how far forward this workforce is already standing.

To understand why the state experiments matter, it helps to understand the machinery they are modifying. A foreign-trained physician seeking a full, unrestricted license in most US jurisdictions must clear a gauntlet of checkpoints: certification by the Educational Commission for Foreign Medical Graduates, a sequence of United States Medical Licensing Examination steps that tests basic science and clinical reasoning, and completion of an accredited residency — four years for psychiatry, from postgraduate year one through postgraduate year four — in a program overseen by the Accreditation Council for Graduate Medical Education. Only then do most state medical boards grant an unrestricted license, with board certification by the American Board of Psychiatry and Neurology functioning as an additional, examination-based credential layered on top. The architecture is deliberately designed as a uniform quality filter. Its critics answer that it is also a decade-long and financially punishing funnel that wastes trained talent: a psychiatrist can be fully licensed, experienced, and in good standing in another country yet legally barred from so much as supervised clinical work across much of the United States.

The counter-movement is now visible on the statute books. The Federation of State Medical Boards maintains a state-by-state chart of enacted and proposed additional licensure pathways for international medical graduates, and the commentary’s authors walk through the leading examples. In Tennessee, legislators amended Title 63 of the state code — the chapter governing the healing arts — through Senate Bill 1451, opening a route for foreign-trained physicians that does not run through the standard residency pipeline. In Virginia, administrative regulation 18VAC85-20-210 establishes “limited licenses to foreign medical graduates,” a category of restricted, supervised practice that permits internationally trained doctors to treat patients before completing a full American residency. These measures build on older infrastructure, most notably the federal Conrad 30 Waiver Program, which each year allows up to thirty physicians per state on J-1 exchange visas to forgo returning to their home countries in exchange for three years of service in federally designated health professional shortage areas. What is genuinely new is the idea of decoupling licensure itself from the completion of US residency training — a structural change rather than a visa adjustment.

The potential upside is what makes the moment electric. Internationally trained physicians are among the most reliable workforce instruments the country has for reaching underserved populations. Research published in the Journal of Health Care Poor Underserved showed that IMGs contribute substantially to diversity in the American physician workforce, and a 2021 commentary in The Lancet Gastroenterology & Hepatology argued that their role in advancing diversity has been chronically undervalued. Khan’s own earlier work in Academic Psychiatry made the case that supporting IMG physicians is one of the few realistic strategies for closing gaps in child psychiatry, one of the most severely underserved subspecialties in the country. A 2024 analysis in JAMA framed international medical graduates as an integral, permanent component of the physician workforce rather than a stopgap. Alternative licensure pathways could convert credentialed, experienced clinicians into practicing psychiatrists in rural counties and inner-city districts where recruitment has failed for decades — and patients who share linguistic and cultural backgrounds with their doctors consistently fare better in treatment engagement and follow-through.

But psychiatry is a moving target across borders, and this is where the technical difficulties begin. A 2021 comparative analysis in European Neuropsychopharmacology examined psychiatry training across forty-two European countries and found striking heterogeneity in program length, the balance between biological psychiatry and psychotherapy, supervision requirements, and examination standards. A worldwide survey of World Psychiatric Association member associations published in International Review Psychiatry reached a similar conclusion on a global scale. A foreign psychiatry residency, in other words, certifies very different things depending on where it was completed, and state medical boards currently possess no common metric for judging equivalency. One candidate solution is the entrustable professional activity, or EPA — a competency framework catalogued in a scoping review in Medical Education Online. Instead of counting months of training, an EPA-based assessment asks whether a physician can be trusted to perform defined clinical tasks unsupervised: conducting a suicide risk assessment, managing an acute psychotic crisis, prescribing psychotropic medication safely across populations. The World Federation for Medical Education’s Basic Medical Education Standards, oriented toward a 2030 horizon, offer a second possible benchmark — though they accredit medical schools, not the current competence of individual graduates.

The commentary’s treatment of unintended harms confronts a more uncomfortable variable: bias. A 2023 scoping review in BMJ Open documented pervasive perceptions of inequitable treatment among international medical graduates, spanning discrimination in selection, supervision, and everyday clinical hierarchies. That same year, a paper in Academic Pathology described a normalized “medical inferiority bias” and cultural racism against IMG physicians embedded within academic medicine itself. The irony is sharp: the presumption of inferiority coexists with decades of evidence that internationally trained doctors prop up exactly the services American medicine struggles to staff. The danger, as the authors frame it, is that poorly designed pathways could institutionalize a two-tier profession — limited-license physicians channeled into the least desirable posts, with lower pay, weaker legal protections, and no credible bridge to full licensure or board certification. Even existing board-level flexibility, such as the American Board of Psychiatry and Neurology’s academic pathway and the American Board of Radiology’s alternate certification routes, covers narrow niches rather than the general clinical workforce, leaving the structural question unresolved.

Then there is the question that animates every medical board hearing: is it safe? A 2025 analysis in the Journal of Graduate Medical Education examined the challenges of removing US residency training requirements for state licensure and found the technical problems thornier than the political rhetoric suggests — how to determine equivalency, how to verify training records across jurisdictions with different documentation cultures, and how to assess skills that may have diverged or eroded with time. A physician’s firsthand account of practicing within both the American and British systems, published in the British Journal of General Practice, illustrates how nontrivial those differences are even between two Anglophone countries with superficially similar medical cultures. The commentary’s authors do not argue for an open border in medical licensure; the architecture of their argument, with dedicated sections on standardization challenges and important considerations, points instead toward guardrails: mandatory supervised practice periods, standardized competency assessments, transparent equivalency criteria, and longitudinal outcome tracking that would let regulators learn from each state’s experiment rather than repeat its mistakes.

What happens next will test whether the United States can mount a coordinated national response to a workforce crisis, or whether it will improvise, state by state, as it usually does. The direction of the authors’ argument is clear: alternative pathways succeed only if they are engineered rather than merely enacted — anchored in validated competency assessments, harmonized across state lines, paired with the mentorship and integration support that resources from the American Psychiatric Association attempt to provide, and evaluated with real outcome data rather than anecdotes. Institutional scaffolding already exists in fragments. The American Medical Association has framed its advocacy as clearing IMGs’ route to practice, the National Institute of Mental Health sustains training programs for physician-scientists that could offer internationally trained psychiatrists academic footholds, and the American Psychiatric Association’s federal affairs arm has made workforce development a standing priority. The alternative to getting this right is a status quo the numbers render untenable. Every qualified psychiatrist kept out of the workforce is a caseload of untreated illness; every pathway built without safeguards risks the public trust on which all of medicine rests. The commentary’s title states the dilemma plainly — pitfalls and potential — and the country is about to discover how much of each it can afford.

The study analyzed records for 249,679 physicians initially certified in internal medicine by the American Board of Internal Medicine between 1990 and 2025. Investigators linked 178,782 of those physicians to Medicare claims, allowing them to examine the patients treated by different groups of doctors. Approximately 36% of the physicians were international medical graduates, or IMGs, who were born outside the United States and attended medical school abroad. Another 11% were born abroad but trained in U.S. medical schools. Together, these groups made up nearly half of the internal medicine workforce represented in the analysis. The researchers used country of birth and medical-school location to distinguish physicians whose professional pathways crossed national borders, rather than treating all IMGs as a single category.

The patient-level analysis revealed a consistent association between non-U.S.-born IMGs and populations that have historically faced greater barriers to healthcare. Among traditional Medicare beneficiaries treated by these physicians, 9.5% were Black, compared with 7% of patients treated by U.S.-born graduates of U.S. MD or DO programs. Latino patients represented 6.6% of the population treated by non-U.S.-born IMGs, compared with 3.9% among patients treated by the U.S.-born physician group. The differences were also evident in measures of economic disadvantage. Nearly 21% of patients cared for by non-U.S.-born IMGs were eligible for both Medicare and Medicaid, a marker often associated with low income and complex healthcare needs, compared with 11.7% of patients cared for by U.S.-born U.S.-trained physicians. Almost 20% lived in ZIP codes with high poverty rates, compared with 15.9% in the comparison group.

These patterns do not mean that a physician’s birthplace determines the kind of patients they treat, nor can an observational study establish that international graduates cause better or worse access to care. Instead, the results indicate that non-U.S.-born IMGs are disproportionately present in the settings where vulnerable patients receive medical services. Factors such as hospital location, specialty choice, employment opportunities, insurance mix and physician recruitment practices may all contribute to the association. Medicare claims also capture only certain aspects of healthcare delivery and do not fully describe patients’ clinical histories, language preferences, transportation limitations or access to physicians outside the traditional Medicare system. Even with those limitations, the scale of the pattern suggests that international physicians are not a peripheral component of American medicine but a structural part of how the system functions.

Their importance was visible across internal medicine subspecialties. Non-U.S.-born IMGs represented at least 27% of physicians in every subspecialty examined by the researchers. In geriatrics, sleep medicine and nephrology, they represented more than half of all physicians. Geriatrics is especially significant because the demand for physicians trained to care for older adults is expected to rise as the population ages. Nephrology faces patients with long-term, resource-intensive conditions such as chronic kidney disease and kidney failure, while sleep medicine addresses disorders linked to cardiovascular disease, metabolic illness, impaired cognition and accidents. A shortage in any of these fields can delay diagnosis, increase reliance on emergency care and complicate the management of chronic disease.

Internal medicine also serves as a major entry point into the American healthcare system. Internists diagnose and manage multiple conditions simultaneously, coordinate care among specialists and often provide continuing treatment for patients whose illnesses become more complicated over time. Physicians who complete internal medicine training may continue into fields including cardiology, medical oncology, rheumatology, infectious diseases, pulmonary medicine and gastroenterology. The study’s workforce estimates therefore extend beyond the image of the general internist: they include doctors whose expertise supports cancer treatment, heart care, immune disorders, respiratory disease and other highly specialized services. In many regions, losing even a small number of these physicians can lengthen wait times and force patients to travel substantial distances for appointments.

The findings also place current immigration policies in a healthcare context. Physicians born in countries affected by U.S. travel restrictions accounted for about 6% of internal medicine doctors in the study. Although restrictions introduced in 2025 and 2026 ultimately exempted physicians, the researchers and physicians involved in the study noted that uncertainty can still have practical consequences. Hospitals may delay recruitment, training or credentialing decisions when visa rules are unclear, and doctors already working in the United States may face administrative disruptions. Reports that some noncitizen physicians from affected countries were placed on administrative leave illustrate how policy uncertainty can reach clinical settings even when formal exemptions exist. At the same time, the National Resident Matching Program reported that the match rate for non-U.S.-citizen IMGs entering U.S. residency programs reached a five-year low in March.

That decline matters because residency training is the principal route through which internationally educated physicians become eligible to practice independently in the United States. After passing required examinations and meeting regulatory standards, IMGs must compete for limited residency positions, often navigating visa requirements, state licensing rules and institutional policies. A reduction in successful matches can therefore produce effects years before a shortage becomes visible in hospital staffing data. The consequences may be particularly pronounced in internal medicine subspecialties that already depend heavily on physicians born abroad. If fewer international graduates enter training, the resulting gap may affect not only the number of available doctors but also the geographic distribution of care, since IMGs have historically helped staff hospitals and clinics serving lower-income and medically underserved populations.

The authors describe their work as evidence for incorporating physician migration and training pathways into national workforce planning. Alicia Fernandez, MD, an ABIM Board director and internist at Zuckerberg San Francisco General Hospital and Trauma Center, said physicians born outside the United States often care for patients with complex conditions and limited access to medical services, providing continuity in communities that may struggle to attract other doctors. Lead author Giacomo Meille, PhD, emphasized that the need is likely to grow as the population ages, especially in geriatrics. The study was conducted by researchers affiliated with ABIM, and several authors disclosed employment or leadership roles with the organization. Those disclosures do not invalidate the analysis, but they are relevant when interpreting research about the workforce of the institution that supported the study.

The central message is both straightforward and consequential: physicians born outside the United States are deeply embedded in American internal medicine, and the patients who rely on them often face greater social and economic vulnerability. In 2024 alone, their care reached tens of millions of Medicare beneficiaries. The data suggest that immigration policy, residency recruitment and specialty workforce planning are not separate from healthcare access; they are mechanisms that help determine who can receive care, where that care is available and whether the system can meet rising demand. As physician shortages intensify, the United States may find that maintaining a stable supply of internists and subspecialists depends not only on educating more doctors at home but also on preserving the international pathways that have long supported American medicine.

Subject of Research: People

Article Title: Non–US–Born Physicians in the US Internal Medicine Workforce

News Publication Date: 12-Aug-2026

Web References: American Board of Internal Medicine: https://www.abim.org/ ; National Resident Matching Program: https://www.nrmp.org/about/news/2026/03/nrmp-releases-results-of-the-2026-main-residency-match-for-more-than-38000-future-residents/ ; U.S. Health Resources and Services Administration physician projections: https://bhw.hrsa.gov/sites/default/files/bureau-health-workforce/data-research/physicians-projections-factsheet.pdf

References: JAMA, “Non–US–Born Physicians in the US Internal Medicine Workforce,” DOI: 10.1001/jama.2026.13268

Keywords: internal medicine, international medical graduates, physician workforce, Medicare, healthcare access, health disparities, geriatrics, nephrology, sleep medicine, immigration policy, physician shortages

The Conrad 30 waiver represents a pivotal policy intervention aimed at mitigating disparities in medical care distribution between urban centers and rural localities. By incentivizing international medical graduates to practice in underserved regions, the program ensures that vital healthcare services reach populations often marginalized due to geographic isolation and insufficient healthcare infrastructure. The scale of this impact is profound, with thousands of J-1 visa holders contributing to the rural healthcare workforce, thereby strengthening local health systems and improving patient outcomes in these settings.

Beyond the J-1 visa and Conrad 30 waiver mechanisms, H1-B visas provide an additional pathway for immigrant clinicians to practice medicine in the United States. While predominantly utilized by specialized physicians and researchers, H1-B visa holders further diversify the medical workforce and contribute to reducing healthcare provider shortages in various regions, including rural areas. These foreign-born healthcare professionals bring a range of expertise and cultural competencies that enhance the quality of health services delivered, especially in areas with specific demographic needs.

The intersection of immigration policy and healthcare provision opens new avenues for addressing longstanding workforce challenges. Physician shortages in rural America have been a persistent issue, exacerbated by declining rural populations, limited access to medical education, and geographic barriers. International medical graduates, enabled by programs like Conrad 30 and visa pathways such as the H1-B, offer essential relief by filling gaps in service coverage, fostering continuity of care, and supporting the sustainability of rural health facilities.

From a demographic standpoint, rural populations are often characterized by older age distributions, higher prevalence of chronic conditions, and socioeconomic disadvantages that heighten their vulnerability to health disparities. The targeted placement of immigrant physicians in these areas aligns with broader public health goals of equity and social justice. By ensuring that vulnerable rural residents have access to consistent, high-quality medical care, these immigration-based programs contribute to improving population health outcomes and reducing preventable morbidity and mortality.

The legislative framework underpinning these immigration pathways reflects a strategic convergence of healthcare policy and federal immigration priorities. The flexibility embedded within the Conrad 30 waiver and related visa categories allows for adaptable responses to dynamic healthcare needs. State-level health departments coordinate with federal authorities to identify critical shortage areas, align physician placements, and monitor outcomes, creating a responsive system that maximizes the impact of international medical graduates’ contributions.

Tracking the migration patterns of immigrant physicians from their initial arrival to their practice locations has become an invaluable tool for policymakers and researchers alike. Migration tracking methodologies employ advanced ecological and demographic approaches to analyze settlement trends, service provision levels, and long-term retention rates in rural communities. Insights gained through these methods facilitate data-driven adjustments to program parameters, ensuring sustained success in bolstering rural health systems with international clinical talent.

The presence of immigrant clinicians in rural contexts also fosters cultural competence and linguistic diversity within healthcare teams. Physicians trained in different health systems and cultural environments enrich clinical practice with new perspectives on patient engagement, disease management, and preventive care. This diversity enhances the responsiveness of rural healthcare services to the unique needs of local populations, including ethnic minorities, indigenous groups, and recent immigrant residents, thereby reducing barriers to effective care.

Internal medicine specialists among international medical graduates play a crucial role given their broad expertise in managing complex adult diseases, preventive medicine, and chronic conditions prevalent in rural settings. Their clinical versatility enables them to address a wide spectrum of patient needs, often compensating for the shortage of specialized care available in geographically remote areas. This breadth of competency is essential for sustaining comprehensive primary care frameworks in communities with limited access to tertiary medical centers.

The interplay between social, political, and scientific dimensions in the deployment of immigrant physicians reveals a multifaceted challenge that transcends simple workforce metrics. Immigration policy decisions have direct health implications, influencing the distribution of scientific and medical expertise across diverse socio-political landscapes. Effective legislation, informed by migration data and healthcare outcomes research, is essential to harmonize these dimensions and promote equitable access to medical science benefits.

As the United States continues to navigate changing demographic and healthcare landscapes, the role of foreign-trained physicians remains an indispensable component of rural healthcare strategies. Protecting and expanding immigration pathways that facilitate their sustained service in underserved locations will be critical in addressing future workforce shortages. Additionally, ongoing research, policy innovation, and cross-sector collaboration are necessary to optimize these mechanisms and ensure that rural populations receive the comprehensive care they deserve.

The impact of immigration-based healthcare workforce policies extends beyond mere numbers, embodying a model of equitable scientific workforce distribution and rural community resilience. Through targeted immigration programs, the United States demonstrates how thoughtful legislative frameworks can harness global medical talent to advance local health equity and scientific progress. The integration of international medical graduates into rural health systems thus symbolizes a vital intersection of scientific endeavor, social responsibility, and legislative innovation.

Subject of Research: Immigration policies facilitating international medical graduates’ service in U.S. rural healthcare settings
Article Title: Not available
News Publication Date: Not available
Web References: Not available
References: (doi:10.1001/jamainternmed.2025.7633)
Image Credits: Not available

Keywords: Physician scientists, Rural populations, United States population, Legislation, Migration tracking, Health care, Geographic regions, Internal medicine

The study, conducted by a team of researchers led by Yakubu, A.O., alongside colleagues Omoleye, O., and Ojoh, U.H., seeks to illuminate the multi-faceted elements affecting residency interview invitations for African IMGs. This demographic is significant, as it comprises a sizable portion of the global healthcare workforce. Despite their varied skill sets and educational backgrounds, these graduates often find themselves facing systemic barriers and biases that can hinder their progression into the medical profession in the U.S.

One of the central arguments presented in the research is the role of educational credentials. African IMGs often graduate from medical schools that are not as well-recognized as their U.S. counterparts. The study suggests that the recognition, or lack thereof, of foreign medical institutions plays a significant role in how residency program directors perceive applicants. Credentials from well-established medical schools boost an applicant’s chances of receiving an interview invitation, while those from lesser-known institutions may be subject to skepticism. This presents an urgent need for changes in how residency programs evaluate international educational backgrounds.

Additionally, the study highlights the importance of standardized testing scores, particularly the United States Medical Licensure Examination (USMLE). It appears that high scores in these exams correlate strongly with increased interview rates. The pressure to excel in these grueling assessments can disproportionately affect African IMGs, who may not have access to the same resources and preparatory tools as domestic candidates. Consequently, the disparities in access to quality education and preparatory resources raise questions about equity and inclusivity within the residency application process.

Another influential factor examined in the study is the networking opportunities available to IMGs. The authors found that connections within the medical field, whether through mentorship programs or professional organizations, significantly enhance an applicant’s visibility and prospects for interviews. However, many African IMGs lack such opportunities, which limits their ability to showcase their qualifications effectively. This revelation underscores the necessity for strategic initiatives aimed at bridging these networking gaps, helping IMGs to establish the necessary relationships within the U.S. medical community.

The study also casts a critical eye on the cultural competencies of residency program directors. It posits that directors who possess a broader understanding of the challenges faced by IMGs are more likely to consider diverse applicants favorably. On the other hand, unconscious biases can lead to the marginalization of African candidates, even when they possess competitive qualifications. This nuanced understanding of bias in recruitment processes is essential for fostering more inclusive residency programs that appreciate the value of diversity in enriching the medical field.

Furthermore, institutional support plays a significant role in influencing residency interview rates for African IMGs. The research indicates that programs equipped with robust support systems, such as counseling and workshops tailored to international graduates, witness higher rates of interview invitations. By providing targeted assistance, institutions can play a transformative role in leveling the playing field for African IMGs and ensuring that their skills are utilized within the U.S. healthcare system.

Additionally, the researchers discuss the psychological impact of the application process on IMGs. Faced with often daunting odds and higher levels of uncertainty, many may experience anxiety and stress, which can ultimately hinder their performance in interviews when granted the opportunity. Addressing these mental health concerns is vital for increasing not only interview rates but also the overall well-being of African IMGs navigating this challenging journey.

The findings and recommendations articulated in this research beckon a call to action within the medical community. First, there is an urgent need for residency programs to review and revise their selection criteria, placing less emphasis on school reputation and standard exam scores while adopting a more holistic approach to evaluating candidates. By doing so, they can recognize the diverse experiences and perspectives that African IMGs bring to the table, contributing to a more vibrant medical workforce.

Moreover, the study advocates for increased investment in mentorship and networking initiatives that specifically target African IMGs. Creating robust support networks can help these graduates to connect with established medical professionals who can guide them through the application process and help them cultivate their skills. As these networks grow, they serve as a catalyst for change, fostering a more inclusive and equitable environment within the realm of medical residency in the U.S.

In conclusion, the research conducted by Yakubu and colleagues not only provides vital insights into the factors influencing residency interview rates among African IMGs but also sets the stage for necessary reforms in the medical education system. Enhancing opportunities for these graduates is not just a matter of fairness; it is a moral obligation to cultivate a diverse and capable healthcare workforce that reflects the complexity of global health. The challenges may be steep, but with concerted efforts and an unwavering commitment to equity, a future where African IMGs thrive within U.S. medical residency programs is achievable.

In a globally interconnected world, the emphasis should always remain on inclusivity, understanding, and support for all medical graduates, regardless of their country of origin. The time has come to recognize the invaluable contributions that IMGs from Africa and beyond can make to the healthcare system, shaping not only their futures but the future of medicine itself.

Subject of Research: Factors influencing United States residency interview rates among African international medical graduates

Article Title: Factors influencing United States residency interview rates among African international medical graduates

Article References:

Yakubu, A.O., Omoleye, O., Ojoh, U.H. et al. Factors influencing United States residency interview rates among African international medical graduates. BMC Med Educ 25, 1213 (2025). https://doi.org/10.1186/s12909-025-07806-3

Image Credits: AI Generated

DOI: 10.1186/s12909-025-07806-3

Keywords: African international medical graduates, residency interview rates, medical education, U.S. residency programs, equity in medical training.