There are almost 1.1 million licensed physicians in the United States. That may sound like a lot, but the country has struggled for decades to train enough physicians to meet its needs – and, in particular, to provide care in rural and underserved communities.

Foreign-born physicians have long filled that gap, reducing the overall national shortage and signing up to practice in often overlooked regions and specialties. Today, 1 in 5 doctors licensed to practice in the U.S. were born and trained in another country.

But the ability of physicians from other countries to obtain work in the U.S. may be threatened by the Trump administration’s aims of limiting foreign workers. In September, Trump issued a proclamation requiring employers sponsoring foreign-born workers through a type of work visa called an H-1B to pay a fee of US$100,000 to the government. The White House has signaled doctors may be exempt but has not clarified its position.

As a physician and professor who studies the intersection of business and medicine, I believe increasing restrictions on H-1B visas for physicians may exacerbate the physician shortage. To grasp why that is, it’s important to understand how foreign-trained doctors became such an integral part of U.S. health care – and the role they play today.

The roots of today’s physician shortage

The Association of American Medical Colleges, a trade association representing U.S. medical schools, estimates there will be a deficit of about 86,000 physicians in the country by 2036.

The roots of this shortage stretch back more than a century. In 1910, a landmark study called the Flexner Report detailed significant inconsistencies in the quality of education at American medical schools. The report resulted in the closure of over half the country’s medical schools, winnowing their numbers down from 148 to 66 over two decades.

As a result, the number of doctors in the U.S. declined until new training programs emerged. Between 1960 and 1980, 40 new medical schools launched with the help of federal funding. In 1980, a congressionally mandated assessment deemed the problem solved, but by the early 2000s, a physician shortage emerged once more. In 2006, the American Association of Medical Colleges called for raising medical school enrollment by 30%.

Growth in medical school enrollment hit that target in the late 2010s, but even so, the U.S. still lacks enough medical graduates to fill yearslong training programs, called residencies, that early-career physicians must complete to become fully qualified to practice.

Especially lacking are primary care physicians – particularly in rural areas, where there are one-third as many physicians per capita as in urban areas.

Opportunities for foreign-born doctors

Even as the U.S. built up medical school enrollment in the 1960s and 1970s, the government joined other countries such as the U.K. and Canada in creating immigration policies that drew physicians from developing countries to practice in underserved areas. Between 1970 and 1980, their numbers grew sharply, from 57,000 to 97,000.

Foreign-born and -trained physicians have remained a key pillar of the U.S. medical system. In recent years, the majority of those physicians have come from India and Pakistan. Citizens of Canada and Middle Eastern countries have added significantly to that count, as well. Most arrive in the U.S. as trainees in residency programs through one of two main visa programs.

The majority come on J-1 visas, which allow physicians to enter the U.S. for training but require them to return to their home country for at least two years when their training is complete. Those who wish to remain in the U.S. to practice must transition to an H-1B visa.

A small percentage of physicians come to the U.S. on H-1Bs from the start.

H-1B visas are employer-sponsored temporary work permits that allow foreign-born, highly skilled workers to obtain U.S. employment. Employers directly petition the government on behalf of visa applicants, certifying that a foreign worker will be paid a similar wage to U.S. workers and will not adversely affect the working conditions of Americans.

Several programs sponsor H-1B visas for physicians, though the most common requires a three-year commitment to work in an underserved area after completing their training.

Foreign physicians fill a crucial need

In 2025, foreign-trained medical graduates filled 9,700 of the nearly 40,000 training positions. Of those, roughly one-third were actually U.S. citizens who attended medical schools in other countries, with the remainder being foreign citizens seeking more training in the U.S.

After residency, these doctors frequently practice in precisely the geographic areas where the physician shortage is most severe. A nationwide survey of international medical graduates found that two-thirds practice in regions that the federal government has designated as lacking sufficient access to health care.

These doctors also occupy a disproportionate number of primary care positions. In a sample of 15,000 physicians who accepted new jobs in one year, foreign-born doctors were nine times more likely to enter primary care specialties. In 2025, 33.3% of internal medicine, 20.4% of pediatric and 17.6% of family medicine training positions were filled by physicians trained in other countries.

Who will pay?

Approximately 8,000 foreign-born physicians received H-1B visas in 2024. The new requirement of a $100,000 sponsorship fee would hit hardest for hospitals, health systems and clinics in areas of the country most significantly affected by the physician shortage.

These organizations are already under economic strain due to increasing labor costs and Medicare payments that have not kept pace with inflation. Dozens of these hospitals have closed in recent years, and many currently do not make enough money to support their operations.

On Sept. 25, 2025, 57 physician organizations cosigned a letter petitioning Homeland Security Secretary Kristi Noem to waive the new application fee for physicians.

Already, however, the new rule may be having a chilling effect. Despite years of annual growth in the number of foreign-born applicants to U.S. physician training programs, 2025 has seen a nearly 10% drop. If the new H-1B fee is applied to physicians, the number is likely to keep falling.

Patrick Aguilar Washington University, an employer of physicians.