By Stacey Butterfield
If attendees at Internal Medicine Meeting 2026 had any doubts about the importance of international medical graduates (IMGs) to health care in the U.S., a panel discussion on Thursday morning should have put them to rest.
Panelist Capt. Eric S. Holmboe, MD, MACP, MC, USNR, began by offering some statistics. “About 17% of all practicing physicians in the United States are foreign nationals who did their medical school elsewhere and finished their training here,” said Dr. Holmboe, who is an internal medicine physician and president and CEO of Intealth, a nonprofit that includes the Educational Commission for Foreign Medical Graduates.
The percentage of foreign-born IMGs (a tally that excludes U.S. citizens who leave the country for medical school and return for residency) is even higher in some states and specialties, he added. “It's 33% of practicing internists that are a foreign national, one in three,” he said. "And if you look at recent matches, it's now over 60% of those matching in nephrology.”
Given those numbers, anyone with aging kidneys (or even more so, those without) has reason for concern about recent federal actions on immigration, which Dr. Holmboe reviewed.
The first move, made last October, was the presidential proclamation on H-1B visa fees. “Essentially, if you're coming from another country on an H-1B, there's been the imposition of this $100,000 fee. It is still in effect. There is bipartisan legislation trying to make its way through Congress to give an exemption to physicians. We'll see where that goes,” he said.
Important things to note about the fee are that it does not apply to visa holders who are already in the U.S. (for example, physicians who move on from residency to fellowship) and that the fee has to be paid by the employer, rather than the visa applicant.
The next policy change on Dr. Holmboe's list, the expanded travel ban, is probably even more consequential for medical practice, he said. “Three of the countries that were added tend to send a fair number of folks here: Iran, Sudan, and Nigeria.” Although there are processes for gaining exceptions, “It's very unlikely” that applicants from those countries will be admitted this year, he said.
On the third point, Dr. Holmboe wanted to provide some reassurance to physician trainees about a recent change. “This immigrant visa pause for 75 countries has created a lot of confusion," he said. "It's important to note that J-1s and H-1Bs are nonimmigrant visas, because they're not meant to be permanent visas to come to the States.”
The other big recent development in IMG practice has come from the states rather than the federal government. Panelist Humayun J. Chaudhry, DO, MACP, reported on work to allow physicians who trained in other countries to become licensed in the U.S. without going through residency.
“We have such a need,” explained Dr. Chaudhry, who is an internal medicine physician and the president and CEO of the Federation of State Medical Boards (FSMB). “It could be as many as 15% of IMGs who apply for residency have already done residency training overseas … so the internationally trained physician (ITP) concept is the one that state boards started talking about.”
State legislatures helped start the conversation and then they moved right past talk to action. “Three years ago, in 2023, is when this really took off, when Tennessee became the first state to actually introduce and very quickly pass a law to enable an additional licensure pathway,” said Dr. Chaudhry.
There are now laws along these lines in 20 states, with legislation introduced in a dozen or so others. However, states making it legal for people to become physicians this way does not resolve the issue of how they get licensed.
“This raised all sorts of questions. How do you do this thoughtfully? How do you do it in a way that doesn't exploit the individuals who go through these programs?” said Dr. Chaudhry. “Many of the state boards or states that were interested in doing this began reaching out to the FSMB, [Accreditation Council for Graduate Medical Education], and Intealth, and that's when we decided we need to do something about this.”
The relevant organizations formed an advisory commission on additional licensing models to hash out plans for pathways. “We tried to be as thoughtful as we could in putting together some recommendations [for state medical boards]. The very first series of recommendations we issued, part one of our guidance, was in February of 2025,” said Dr. Chaudhry.
The recommendations address issues such as the education and training required in the home country, how long it can be since the applicant trained or practiced, and what kinds of supervision are required before full licensure.
“The ITP pathway is not for the person who graduated from medical school 20 years ago, has lived in United States, and is maybe doing other things. This is for someone who has some currency in their knowledge and skills,” noted Dr. Chaudhry.
The next step in the pathway-building process will be for state medical boards to set up systems for physicians to apply and train. “That can take as long as a year to make sure that everything was put together thoughtfully. So as of today, we have less than a dozen ITPs who are currently in these pathways,” he reported.
The biggest barrier to having more physicians enter the queue may come back to the H-1B fee, he noted. “Because individuals going through ITP pathways are not residents in training, it's not going to be the J-1 training visa they're coming in on," Dr. Chaudhry said. “Most employers are not going to be able to pay for that … If that exception is not made for health care workers, this doesn't really go anywhere, even though the states are very interested in doing this.”
Getting an exception to the H-1B fee for medical residents, fellows, and physicians is also on ACP's list of priorities for 2026. The session's moderator, former ACP President George M. Abraham, MD, MPH, MACP, highlighted the important and growing role IMGs play within the College.
“Our participation, as an international medical graduate community in the roles of the College, has doubled. From 11%, we went to 22% and we are continuing to climb,” he said. ■