International medical graduates (IMGs) play a vital role in the United States healthcare system, particularly in the field of infectious diseases (ID). They account for a substantial proportion of trainees and practicing physicians. IMGs represented 24.7% of the U.S. physician workforce and 39% of ID fellows in 2023. They underscore their importance in sustaining this specialty. They are more likely to work in underserved and rural areas helping to address disparities in access to care. IMGs face many challenges specifically related to complex immigration pathways and limited institutional support. At the same time, applications to infectious diseases training programs have declined in recent years, increasing reliance on IMGs to sustain workforce capacity.
The published study in Open Forum Infectious Diseases aimed to assess the experience, challenges, and support needs of IMG fellows and recent graduates in ID programs with a focus on visa processes, institutional resources, and career decision-making. A needs assessment survey was conducted in March to April 2025 by using an anonymous, internet-based questionnaire distributed by program directors (PDs). PDs were asked to share the survey with IMGs currently in fellowship or those who had graduated in the past 3 years.
A separate program director (PD) survey tracked the number of individuals contacted. The survey remained open for four weeks, with a reminder sent midway. Eligible participants were graduates of medical schools outside the U.S. or Canada who were either in training or recent graduates. The survey used branching logic to tailor questions based on training status, and respondents could skip questions. Ethical approval was deemed exempt because of the voluntary and anonymous nature of participation. Data were analyzed by using descriptive statistics with results summarized as frequencies and percentages.
A total of 69 responses were received, with 56 meeting inclusion criteria. From these, 48% were current fellows and 52% were recent graduates. Most respondents (76%) were on J-1 visas, 12% held H-1B visas, and 12% were U.S. citizens or permanent residents. The majority (86%) had completed an Accreditation Council on Graduate Medical Education (ACGME)-accredited residency in the U.S. Institutional support differs considerably: only 27.3% of institutions sponsored H-1B visas and 59.1% did not. Perceived institutional understanding of visa onboarding ranged from low or none (24%) to moderate (28%) and good or excellent (48%). Only 42.9% of respondents reported access to individualized visa counseling.
More than half of respondents (55.8%) sought visa-related guidance when applying for fellowship; of these, 69.6% found the advice mostly accurate, while only 13% considered it completely accurate. Understanding of post-fellowship career options remained limited, with many reporting only partial clarity. Among recent graduates, 74% sought visa advice when applying for their first job, and 70.6% reported it was mostly accurate. However, about one-third indicated that program leadership did not provide meaningful support in navigating visa-related career decisions.
Visa status had a substantial impact on career decisions, influencing specialty choice (40%), selection of academic versus non-academic paths (64.1%), and geographic location of employment (76.9%). Satisfaction with post-fellowship career options was mixed, with more than half of respondents reporting dissatisfaction.
Respondents who had access to individualized visa counseling or who perceived stronger institutional understanding of visa processes reported higher satisfaction and better understanding of their career pathways. This indicates a strong association between support systems and outcomes.
The study explored potential policy changes. About 35% of respondents indicated that reducing state level licensure barriers would greatly influence their career decisions. All respondents reported they would be more likely to pursue subspecialty training in the U.S. if board certification pathways allowed them to avoid repeating residency.
About 89% stated that they would be more likely to remain in the U.S. if such reforms were implemented. Respondents identified several key unmet needs, including clearer information on visa options such as J-1 waivers, mentorship for career transitions, support with job searches, and education on compensation models, contracts, and the business aspects of medicine.
IMGs are essential to the ID’s workforce, but they face major challenges related to visa complexity, inconsistent institutional support and limited career guidance. Visa status greatly shapes their career decisions and often restricts flexibility in specialty choice, practice setting, and geographic location. Improving institutional resources, mentorship, and providing structured visa guidance can improve satisfaction and retentions. Policy reforms aimed at streamlining licensure and board certification pathways can help to attract and retain IMGs. It ensures the continued strength and sustainability of the ID workforce in the U.S.
Reference: Chow B, Mena Lora AJ, Luther VP, et al. Bridging the Gap: A Needs Assessment of Resources and Support for International Medical Graduates Navigating Visa-related Career Decisions in Infectious Diseases. Open Forum Infect Dis. 2026;13(4):ofag183. doi:10.1093/ofid/ofag183
