Doctors Given Borders: The Causes and Costs of US IMG Concentration in Primary Care

BY GRACE UDOH

The United States is facing a healthcare workforce shortage projected to reach a crippling 3.2 million by the year 2026¹. These numbers are not expected to decrease anytime soon, with an average of 1.8 million job openings in various areas of the US healthcare system every year². International Medical Graduates have been identified as the resource to meet this need. International Medical Graduates, or IMGs, are physicians that have graduated from medical school outside of the country in which they intend to practice³. Upon entering the United States, IMGs are required to take part in a domestic residency program before receiving a legal medical license to practice. IMGs have become critical to the continued advancement of the US healthcare system today.

Aside from bridging the deficit in healthcare providers in the United States, IMGs also provide a solution in efforts to meet the needs of an increasingly diverse American population, encouraging linguistically and culturally competent healthcare services. Although federal law prohibits medical discrimination through Act VI of the 1964 Civil Rights Act, inequalities and medical biases continue to permeate the US healthcare system and influence healthcare practice. In a critical investigation of patient care strategies implemented by various medical organizations, researchers identified multiple indicators of negative patient care provisions. Minority populations often feel discouraged from taking advantage of healthcare services due to a lack of information about the organization of healthcare systems, legal hurdles, and procedures typical of specific healthcare services, in addition to language barriers and discrimination from healthcare providers⁴.

Cultural competency healthcare practices work to remove these barriers. Generally, the concept of cultural competency is defined as “a set of congruent behaviors, attitudes, and policies that come together in a system, agency or among professionals and enable that system, agency or those professions to work effectively in cross-cultural situations”⁵. According to the American Medical Association, in the year 2020, IMGs from over 100 countries matched with residency programs in the United States³. International medical graduates help to create a more tolerant and culturally competent medical environment by introducing various perspectives from different nations and cultures. A heterogeneous workforce encourages medical practitioners to value diversity and cultural awareness, values which will transfer over to physicians’ treatment of their patients and ultimately improve physician-patient interactions and patient outcomes.

However, with this marked increase in the percentage of IMGs in the US healthcare workforce, an interesting trend has emerged: according to the National Institutes of Health, IMGs make up approximately 23% of practicing physicians in the United States. Recently an upward trend has been discovered of IMG physicians choosing to specialize in primary care. A 2022 study published in the Journal of Graduate Medical Education found 62% of IMG physicians in the United States to be concentrated solely in primary care⁶.

The choice to pursue a career in primary care as opposed to specialty care can carry many implications for their careers. To understand these implications, it is first important to understand what primary care encompasses. The National Institutes of Health defines primary medicine as care that is “first and fundamental”⁷. In the United States, the specialties of internal medicine, gynecology, pediatrics, and family medicine are broadly categorized into primary care and are typically minimally invasive checkups⁸. Contrastly, specialty healthcare describes very specific areas of practice in which physicians undergo additional training to become experts. Examples of medical specialized care include neurology, ophthalmology, and dermatology.

Primary and specialty career paths are very distinct. Generally, specialty care is seen as a more appealing career choice than primary care. An article published in the Journal of the Association of American Medical Colleges investigates the motivations behind residency students’ choice in specialty through a survey of medical students. The survey concluded that fewer domestically graduated physicians are choosing to specialize in the primary care fields. The research team largely attributed this decline to the large debt in which students find themselves after medical school and the allure of the prestige and lifestyle of non-primary specialized medicine⁹.

The economic benefits of specialty care are also motivating factors for medical students. A study published in the same journal expands on the financial implication of pursuing careers in primary care as opposed to secondary specialty care. Researchers compared scenarios and clearly showed not only the economic benefits of pursuing higher-paying specialties, but also that specializing in primary care often demands trade-offs such as residing in areas with lower costs of living and extending debt repayment plans¹⁰. The push of IMGs into these less desirable primary care roles is alarming and potentially stifling to their transition to the United States as these career choices directly impact these physicians’ economic success and wellbeing.

Although many immigrant physicians become more likely to obtain visas when they pledge to meet the dire need for primary care in areas that are often less attractive or glamorous to American physicians, there are many non-governmental reasons for this concentration in primary care. Transitioning to the US healthcare system includes a host of challenges for IMGs.

IMG doctors recounted their early careers in the US healthcare system in interviews conducted through the University of Washington. Without nearby support systems established through medical school, IMG doctors oftentimes have limited access to career advancement, fellowships, and networking opportunities. In addition to this, immigrants often face unique financial obligations of remittances, US medical exam costs, English language classes, among others which encourages them to begin gaining medical practice and enter the health workforce as quickly as possible¹¹. Interviews with IMGs have identified other social challenges that IMGs experience in their transition to the US that also may motivate their concentration in primary care. In interviews with IMGs in different stages of residency, a research team made up of pediatric professors at the University of Alberta identified recurring challenges IMGs face such as “costly decisions, unspoken expectations, the stigma associated with being an IMG, and fears of being an IMG”¹². These issues were further exacerbated by feelings of a lack of government support and guidance in navigating social services and public infrastructure¹¹. These social challenges discourage physicians from pursuing specialized or competitive residency programs and healthcare fields.

As the United States continues to rely on IMGs to bridge the growing health workforce shortage of primary healthcare professionals, we must acknowledge the external social and economic forces that encourage these doctors to fill these gaps. As organizations such as the American Medical Association and the National Residency Match Program strive to build support and adjustment systems for IMG groups, it is important that these efforts are holistic in addressing and acknowledging the factors within and without the walls of the hospitals or medical practices. There is a harmful pattern in the professional growth of immigrants in the United States. Primary care is recognized as one of the lowest paid of all medical specialties, and increasingly immigrants are expected to fill these roles. The significant concentration of immigrants in these roles is alarming and contributes to the barriers of ethnic diversity and representation in secondary healthcare and specialized medicine.

Diversity consultant Verna Myers makes a distinction: “Diversity is being invited to the party, Inclusion is being asked to dance.” IMGs will continue to act as a solution to the United States healthcare worker shortage. As the US health workforce becomes increasingly diverse as a result, it is crucial that we continue to examine and dismantle harmful and divisive practices within our public institutions. Understanding and identifying these challenges and motivations faced by IMGs is crucial to create a more holistic support system for IMG doctors and to ultimately ensure diversity and inclusion in the United States healthcare system.

Grace Udoh is a first-year in Berkley College.

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References

1. American Hospital Association. Fact Sheet: Strengthening the health care workforce. (2021). https://www.aha.org/fact-sheets/2021-05-26-fact-sheet-strengthening-health-care-workforce
2. Bureau of Labor Statistics. Occupational Outlook Handbook. https://www.bls.gov/ooh/
3. American Medical Association. International Medical Graduates (IMG) toolkit: Types of visas & FAQs. (2025). https://www.ama-assn.org/education/international-medical-education/international-medical-graduates-img-toolkit-types-visas
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10. Youngclaus, J.A., Koehler, P.A., Kotlikoff, L.J. & Wiecha, J.M. Can medical students afford to choose primary care? An Economic Analysis of Physician Education Debt Repayment. Acad. Med. 88, 16–25 (2012).
11. Achkar, M.A. et al. Integrating Immigrant Health Professionals into the U.S. Healthcare Workforce: Barriers and Solutions. J. Immigr. Minor. Health 25, 1270–1278 (2023).
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