Physicians born abroad make up nearly half of U.S. internal medicine. Now two federal visa changes are hitting that workforce at once, and hospital leaders say the pileup is the real danger.
The changes landed within weeks of each other. On Aug. 24, the Trump administration proposed a permanent $103,265 fee on H-1B visa petitions — a figure that would replace the $100,000 version a federal judge struck down in June, and also dwarfs the $2,000 to $5,000 hospitals previously paid. Weeks earlier, the Department of Homeland Security finalized a separate rule, effective Sept. 15, capping J-1 physicians at four years, no matter how long their training actually runs.
Roughly 16,000 to 17,000 residents and fellows train on J-1 visas at more than 770 teaching hospitals. Resident physicians in programs that run longer, such as general surgery at five years and neurosurgery at seven, will now have to obtain an extension from U.S. Citizenship and Immigration Services partway through.
The panic came first, the worry came later
When the $100,000 H-1B fee first surfaced, the initial reaction triggered fear and apprehension.
“It caused literal panic overnight,” said Peter Pronovost, MD, PhD, chief quality and clinical transformation officer at Cleveland-based University Hospitals. “People were thinking, ‘I’m going to be deported, I have to leave.’ That turned out to not be the case.”
What replaced the panic is trepidation: no one yet knows the rules well enough to plan against them.
“Until you know what the rules are, it’s very hard to implement or defend against that,” Dr. Pronovost said. A health system can model what happens if it loses every visa-dependent trainee, he added — but acting on that model before the rules are final is far too expensive to justify.
And the exposure is not only a headcount problem. Residents and fellows on visas provide care that people need Dr. Pronovost said.
His concern isn’t any single rule. It’s all of them at once: New visa policies stacked on 340B program changes and a half-dozen other federal changes moving in parallel.
“Any one of them alone could be pretty impactful for a health system,” he said. “But they’re pulling the levers almost individually; multiple of them happening at the same time would likely be devastating for many health systems.”
How the visa rules weigh on residency programs
At the University of Nevada, Reno School of Medicine, the strain already has a face. Internal medicine is “the most impacted by the need for visas, especially J-1 visas,” said David Carlson, MD, associate dean and designated institutional official for graduate medical education at the university. The medical school’s two main affiliates are Renown Health and VA Sierra Nevada, which are both based in Reno.
This year, several international medical graduates who needed visas could not start on time. All but one eventually did. “One actually did not make it,” Dr. Carlson said.
Off-cycle starts don’t stay contained to one trainee — they ripple through call schedules, patient care and residents’ own families. The four-year cap threatens to make that structural. Dr. Carlson is planning a general surgery residency for around 2028 or 2029; a five-year program under a four-year visa means applicants would enroll already knowing they’ll need an extension — one that lets them keep working for up to 240 days while it’s pending.
His programs already do not accept H-1B visas due to cost and sponsorship, so the new fee barely registers; the J-1 rule is the one that bites. What he wants is narrow: a carve-out for training accredited by the Accreditation Council for Graduate Medical Education, sparing accredited residencies and fellowships from rules like the four-year limit.
The effect on patients
The workforce at risk also treats a distinct set of patients. Physicians born abroad made up 47.2% of the internal medicine workforce and were more likely than U.S.-born physicians to treat historically underserved patients — Black (9.5% versus 7%), Latino (6.6% versus 3.9%) and dually eligible for Medicare and Medicaid (20.9% versus 11.7%), according to a research letter from the American Board of Internal Medicine published Aug. 12 in JAMA.
In geriatrics, sleep medicine and nephrology, non-U.S. citizen physicians account for more than half the workforce. And the pipeline is already thinning: this year’s match rate for non-U.S. citizen international medical graduates fell to 56.4%, a five-year low the National Resident Matching Program tied to federal immigration changes.
For now, leaders are doing the only thing they can: watch and wait.
Dr. Carlson said the University of Nevada, Reno isn’t changing how it evaluates international candidates, whom it still judges on merit, but he expects program directors to grow more cautious about applicants’ visa needs.
He warned the fallout would reach Nevada’s physician workforce broadly, and research suggests rural areas are the most exposed: a JAMA Internal Medicine research letter published Feb. 2 found rural communities depend more heavily on international-born physicians and concluded their access to care “may be particularly sensitive to immigration restrictions.”
“It does have an impact on our workforce,” Dr. Carlson said, “both in the rural area and, quite frankly, in our urban areas.”
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