Supporting International Medical Graduates to Bridge the Primary Care Physician Shortage

We appreciate the article by Songara et al,¹ which examined milestone ratings of international medical graduates (IMGs) and US medical graduates using extensive data from the American Board of Family Medicine. A quarter of practicing family physicians and residents are IMGs,¹ highlighting their importance in providing excellent care, given the rising shortage in primary care physicians.²

Despite efforts to increase positions in family medicine residency programs,³ only 11.2% of all US medical graduates matched into family medicine. In contrast, the number of non-US IMGs who matched into family medicine in 2025 reached a record high, increasing nearly two-fold since 2021.^4,5 These data show a trend that unless major changes are made in US medical education, family medicine residency positions will increasingly be filled by non-US IMGs.

Existing systems for retaining non-US IMGs play a critical role in sustaining the primary care physician workforce. Currently, most non-US IMG residents hold J-1 visas,⁶ which are sponsored by the Educational Commission for Foreign Medical Graduates and are relatively easy to obtain for residents and fellow at a low cost. H-1B visas, on the other hand, are sponsored by the employer, and the cost was historically $ 3,000 to $ 4,000 per applicant.⁷ Medical trainees with J-1 visas are required to return to their home country for 2 years after training.⁸ Alternatively, they can obtain an H-1B visa through J-1 waiver programs by working in rural, urban, and underserved areas or academic institutions.^7,8

In September 2025, a presidential executive order applied an additional $ 100,000 fee to be paid by the employer upon initial application of the H-1B visa to “protect the American workers.”⁸ Physicians sponsored by H-1B visas disproportionately work in rural counties and areas with high poverty rates.⁹ In the past, 60%–80% of IMG physicians on J-1 visas opted to stay in the United States post training.⁶ However, the significantly higher fee for H-1B visa applications could trigger further shortages in the primary care workforce, especially in underserved communities.

It is critical that IMG family physicians trained in the United States are able to practice in the United States in order to address the physician shortage. We acknowledge the American Academy of Family Physicians (AAFP) for joining the American Medical Association and 53 physician organizations in an open letter requesting an exception to the H-1B visa fee for all physicians, including trainees and researchers.¹⁰ We should continue to advocate for waiving the cost-prohibitive H-1B visa fee and expansion of the current J-1 waiver program, which has been shown to facilitate the placement of physicians in underserved communities. We urge all family physicians to connect with their state chapter of AAFP and write to local government officials and members of Congress to advocate for the expansion of these programs.