Nearly half of internal medicine's workforce was born abroad, new JAMA study finds

Physicians born outside the United States make up 47.2% of the internal medicine workforce and treated 22.5 million traditional Medicare beneficiaries in 2024, according to an American Board of Internal Medicine (ABIM) study published Aug. 12 in JAMA.

Non-U.S.-born physicians are concentrated in the subspecialties primary care leans on hardest, including geriatrics, nephrology and sleep medicine, and their patients skew poorer, sicker and more rural than the patients treated by U.S.-born graduates of U.S. medical schools. Policies that slow their entry show up downstream in referral wait times and call coverage.

What the study measured

Researchers examined all 249,679 physicians initially certified in internal medicine by ABIM between 1990 and 2025, then linked 178,782 of them to 100% traditional Medicare claims from 2024 using National Provider Identifiers.

Non-U.S.-born international medical graduates (IMGs) accounted for 36.1% of the 2026 workforce. Another 11.1% were born abroad but trained at U.S. medical schools, split between 9.5% MDs and 1.6% DOs. Together, that is 47.2%.

India and Pakistan contributed the largest shares of non-U.S.-born IMGs, at 10.8% and 3.8% of the internal medicine workforce respectively. Physicians born in the 39 countries covered by current U.S. travel restrictions made up 6% of the workforce.

The share of non-U.S.-born physicians rose from 34.9% of those initially certified in 1990-1994 to 54.2% of those certified in 1995-1999, then declined after 2015, reaching 44.5% among physicians certified in 2020-2025.

Which patients do these physicians treat?

Patients treated by non-U.S.-born IMGs were more likely to be Black (9.5% vs. 7%), Latino (6.6% vs. 3.9%), originally Medicare-eligible on the basis of disability (13.8% vs. 11.1%) and dually eligible for Medicare and Medicaid (20.9% vs. 11.7%) than patients treated by physicians who were born in the U.S. and trained at U.S. medical schools.

They were also more likely to live in high-poverty ZIP codes (19.8% vs. 15.9%), in areas designated medically underserved (21.5% vs. 19.9%) and in primary care shortage areas (30.3% vs. 29.2%).

The gap widened in the first three years after training, the window covered by the Conrad 30 waiver program, which allows physicians on J-1 visas to remain in the U.S. if they practice in underserved areas.

“In many underserved communities, physicians born outside the U.S. care for patients with complex medical conditions and limited access to care,” said co-author Alicia Fernandez, M.D., an ABIM board director and professor of medicine at the University of California, San Francisco, who practices as an internist at Zuckerberg San Francisco General Hospital and Trauma Center.

Where the reliance runs deepest

Non-U.S.-born IMGs make up at least 27% of every internal medicine subspecialty the researchers examined, and more than half of internal medicine-certified geriatricians, sleep medicine physicians and nephrologists.

HRSA's National Center for Health Workforce Analysis already projects a national shortage of 141,160 full-time-equivalent physicians by 2038, with 30 of the 35 specialties it tracks in deficit. Geriatrics is projected at 84% supply adequacy, nephrology at 85%, general internal medicine at 83% and family medicine at 76%.

HRSA projects 2038 supply adequacy of 42% in nonmetro areas against 95% in metro areas, a rural shortfall roughly 12 times deeper than the urban one.

“As the nation's population ages, demand for care continues to grow, especially for physicians certified in subspecialties such as geriatrics, which relies extensively on physicians born outside the United States,” said lead author Giacomo Meille, Ph.D., senior health services researcher at ABIM.

Is the pipeline already narrowing?

Non-U.S. citizen IMGs posted a PGY-1 match rate of 56.4% in the 2026 Main Residency Match, the lowest in five years, even as their applicant pool grew by 479 to 11,944, according to the National Resident Matching Program.

Foreign-born IMGs requiring visa sponsorship matched at 54.4%, a five-year low, while those who did not require sponsorship, meaning U.S. permanent residents, matched at 67.9%, a five-year high.

By comparison, U.S. MD seniors matched at 93.5% and U.S. DO seniors at 93.2%. Physician organizations pressed U.S. Citizenship and Immigration Services through the spring for a carve-out from the processing freeze tied to the travel restrictions. In early May, the agency updated its website to indicate that applications associated with medical physicians would continue processing.

What should practices that sponsor physicians be doing?

Practices should tighten their documentation and start renewal planning earlier, said Katie Russell, J.D., a partner at Brown Immigration Law in Cleveland, who advises medical practices on immigration compliance and appeared on an episode of “Off the Chart: A Business of Medicine Podcast”.

The shift has been “less about having dramatic raids, and it's more about scrutinizing compliance documentation,” Russell said, pointing to Form I-9 completion, record retention and adherence to the terms of approved visa petitions.

“Health care employers are subject to the same employer compliance standards as any other industry,” Russell said, calling the opposite assumption a common misunderstanding among practices hiring physicians on work visas.

The $100,000 H-1B payment created by a September 2025 presidential proclamation applied only to petitions requiring consular processing abroad, not to physicians already in the U.S. changing status from a student or training visa. A federal judge in Massachusetts vacated the policy implementing the payment on June 8, briefly stayed his own ruling on June 12, and the 1st U.S. Circuit Court of Appeals declined to reinstate the payment on July 24. USCIS updated its guidance July 28 to reflect that the payment is not currently enforceable, while the Department of Homeland Security has said it intends to collect if the order is lifted. The underlying proclamation is written as a 12-month restriction set to expire Sept. 20 unless extended.

A federal judge in Massachusetts vacated the policy implementing the payment on June 8, briefly stayed his own ruling on June 12, and the 1st U.S. Circuit Court of Appeals declined to reinstate the payment on July 24.

USCIS updated its guidance July 28 to reflect that the payment is not currently enforceable, while the Department of Homeland Security has said it intends to collect if the order is lifted. The underlying proclamation is written as a 12-month restriction set to expire Sept. 20 unless extended.

Speaking earlier this year, before the courts intervened, Russell said the payment reached fewer petitions than its headline number suggested. “It's not every H-1B. It's many, and it is going to make [it] harder for folks overseas that are looking to come work in the United States,” she said. When it does apply, “all fees need to be paid by the sponsoring employer.”

“The H-1B is not the only game in town,” Russell said, noting that permanent residency sponsorship is sometimes faster, cheaper or better suited than the route a practice defaulted to last year.

“The first thing we do after an approval is we go into our system and go, all right, it expires on this date,” Russell said, describing how her firm tracks renewal deadlines.

Patients “shouldn't have to be worried about, you know, should I skip this doctor's appointment because I'm afraid that an agent or an officer may come through,” Russell said. Survey data has already linked immigration fears to delayed medical care and skipped visits.

One pipeline widening

ABIM opened a competency-based special consideration pathway in July, allowing IMGs who completed internal medicine residency abroad and were accepted into ACGME-accredited U.S. subspecialty fellowships to sit for the Internal Medicine Certification Exam. More than 150 physicians are in the pilot, with exams beginning in August and subspecialty exams as early as 2027. ABIM has identified at least 4,000 physicians across subspecialties who may be eligible.

More than 150 physicians are in the pilot, with exams beginning in August and subspecialty exams as early as 2027. ABIM has identified at least 4,000 physicians across subspecialties who may be eligible.

Recent immigration policy changes may substantially affect internal medicine subspecialties that depend heavily on non-U.S.-born IMGs and may further widen health care access disparities among underserved populations, the study's authors wrote.