International Medical Graduates and the Shortage of US Pathologists: Challenges and Opportunities

IMGs are individuals who receive a basic medical degree or qualification in a country other than the territory of interest.^7,8  IMGs, also known as foreign medical graduates, account for a significant proportion of US GME trainees and a significant proportion of the specialists in all fields of medicine in the United States.^9–12  The broad group of IMGs includes both US citizens (US IMGs) and non-US citizens (non-US IMGs).

The distinction between IMGs and individuals who receive their medical degree from a US institution, known as American medical graduates, is important because of broad differences between the United States and other countries in the content of medical education (both quantity and quality), opportunities, limitations, and other inherent characteristics. To address these differences, the Accreditation Council for Graduate Medical Education and the Educational Commission for Foreign Medical Graduates have for decades had in place programs to ensure that the medical training of IMGs meets stringent requirements and that IMGs are proficient in clinical knowledge and communication skills before they can be considered for medical training and practice in the United States.^8,13  The professional roles and responsibilities of US IMGs, non-US IMGs, and American medical graduates are considered equal for purposes of GME training fulfillment.

According to historical data on the Main Residency Match published by the National Residency Matching Program, the total number of applicants for GME residency positions increased from 28 649 in 1984 to 47 675 in 2022; the number of non-US IMG applicants increased from 7143 (25%) in 1984 to 10 094 (21%) in 2022; and the number of US IMG applicants increased from 2922 (10%) in 1984 to 6608 (14%) in 2022.^14,15 

In pathology, the number of residency positions available increased from 479 in 1984 to 631 in 2022. The number of non-US IMG applicants successfully matching to pathology residency programs increased from 35 (7.3% of total applicants) in 1984 to 212 (33.6% of total applicants) in 2022.^14,15 

A report on the characteristics of IMGs who matched to pathology residency programs in the 2018 Main Residency Match showed that compared with US IMGs, non-US IMGs had a higher mean United States Medical Licensing Examination (USMLE) Step 1 score (230 versus 226); mean USMLE Step 2 score (233 versus 230); mean number of research experiences (2.7 versus 2.1); mean number of abstracts, presentations, and publications (11.5 versus 5.0); mean number of work experiences (4.5 versus 4.3); percentage of applicants with a PhD (21.6% versus 10.0%); and percentage of applicants with another graduate degree (32.8% versus 27.1%).⁷ 

Non-US IMGs face many challenges before, during, and after the residency match process. A report published by USMLE Sarthi estimated the total expenses incurred by each IMG in the year 2021 was approximately $21 000 to $25 000. These expenses included match-related international travel expenses, lodging fees, and other expenses related to IMG status.¹⁶  For example, non-US IMGs need to submit a large number of interview applications because it has been well established that applicants with a longer rank order list (for both American medical graduates and IMGs) are more successful than those with a shorter rank order list,⁷  and evidence suggests that IMGs must submit more interview applications than US MD seniors to receive the same number of interview offers.¹⁷  Results of the 2022 National Residency Matching Program Applicant Survey revealed that for all specialties, the median number of applications submitted was 45 for US MD seniors but 120 for “other applicant types,” including non-US IMGs. Similarly, the median number of interviews offered was 16 for US MD seniors but 7 for IMGs (US IMGs and non-US IMGs combined). In pathology, US MD seniors submitted a median of 25 applications and were offered a median of 16 interviews, whereas IMGs (US IMGs and non-US IMGs combined) submitted a median of 90 applications and were offered a median of 10 interviews.¹⁷ 

A National Residency Matching Program report titled “Impact of Length of Rank Order List on Match Results: 2004-2023 Main Residency Match” showed that the mean number of programs on the rank order list from 2004 to 2023 was 11.2 (range, 7.99–14.31) for US MD seniors, 8.4 (range, 6.2–9.9) for US IMGs, and 7.0 (range, 6.46–7.53) for non-US IMGs. For US MD seniors, the number of programs on rank order lists has been steadily increasing during the last 20 years, whereas for non-US IMGs, the number of programs remained relatively steady from 2015 to 2023.¹⁸  US IMGs demonstrated a greater number of contiguous ranks in pathology than non-US IMGs, as evidenced in the abovementioned report on the 2018 Main Residency Match (8.8 versus 7.8).⁷  Post-match results from 2022 demonstrated that the proportion unmatched was higher for non-US IMGs (44%) than for US MD seniors (6.7%),^14,15  a trend in line with results observed during the preceding 20 years.

The National Residency Matching Program's report Charting Outcomes in the Match: International Medical Graduates states that IMGs who are successful in the match are more likely to be US citizens.⁷  One of the main factors that influence whether non-US IMGs are selected for interviews and obtain residency positions in the United States is whether they require a visa for training in the United States. A multivariate logistic regression analysis of IMGs performed during 2017–2019 found that applicants who needed a visa had a 70% lower chance of matching (odds ratio, 0.3; 95% CI, 0.1–0.8; P = .01).¹⁹ 

The visa most commonly issued to non-US IMGs for GME training is the J-1 visa, also known as the exchange visitor visa. Less commonly issued is the H-1B visa, which is given to individuals with specialty occupations and specialized knowledge. Both are considered temporary (nonimmigrant) visas, but they have widely different implications for training opportunities and future practice.^9,20,21 

J-1 visas are sponsored through the Educational Commission for Foreign Medical Graduates, have a maximum duration of 7 years (in a few cases up to 8 years), and are offered by training institutions more frequently than H-1B visas. Advantages of J-1 visas over H-1B visas include faster processing times and more opportunities for residency and subspecialty training. Nonetheless, for many trainees, the disadvantages may outweigh the benefits. J-1 visa holders are subjected to recurring annual fees, stringent international travel regulations, and, most importantly, much more challenging transition to independent practice compared with H-1B visa holders, US permanent residents, and US citizens. Currently, the time of validity (time from issuance to expiration) of a J-1 visa in GME training institutions is roughly 12 months, which means that visa holders must reapply yearly.²⁰  For GME trainees who wish to travel internationally, revalidating the J-1 visa is an essential step of the process that can be a challenging feat depending on the country of origin, accessibility of a US embassy or consulate, time allotted for renewal, and variable processing times. In addition, political and epidemiologic factors may deeply influence this process, as occurred recently with travel restrictions and suspension of visa processing during the COVID-19 pandemic.^21,22 

Perhaps one of the most challenging aspects of the J-1 visa for physicians who enter pathology training is the transition to independent practice. After completion of residency and fellowship under a J-1 visa, the physician must either return to their home country under the “two-year home-country residence requirement” or obtain a waiver for this requirement.^12,23  Not all physicians with J-1 visas wish to continue their professional careers in the United States; however, those who wish to stay in the United States permanently or temporarily after their GME training ends have a daunting task ahead. Although several paths are available to obtain a waiver, the most common path, and perhaps the only path open to many, is to locate an interested party within a medically underserved area and/or health professional shortage area. A few programs and economic growth commissions are currently available to formalize this process; however, most of these have been historically targeted primarily for primary care positions.^9,24  Thus, there is always uncertainty from both applicants and employers regarding the availability of these positions for pathologists. Most pathology residents complete at least 1 fellowship, and up to 40% are reported to complete 2 fellowships.²⁵  This essentially means that most pathologists are considered specialists, not primary care physicians. Ultimately, the strict rules that apply to J-1 visas translate to increased anxiety and uncertainty from both parties whenever a pathologist with a J-1 visa applies for a job, regardless of the quality of medical training.

H-1B visas are sponsored by the training institution, have a maximum duration of 6 years, and facilitate transition to independent practice. Some limitations of H-1B visas include the cost (paid by training programs), lengthy processing times, and limited availability.²⁰  Factors that have greatly limited availability include a federally mandated cap (65 000 per year, per the US Citizenship and Immigration Services website²³) and reported cuts to federal funding for GME. Although university-affiliated institutions are not limited by the H-1B cap, some authors have stated that these institutions have reported concerns about reputation when offering sponsorship.¹¹  A concern from non-US IMGs is that the proportion of residency programs that sponsor H-1B visas for training has decreased in the last few years, which greatly limits options for residency and subspecialty training.¹²  Although it is possible to obtain an H-1B visa and permanent residency, many physicians struggle with extensive waiting periods, which range from years to decades depending on the country of origin.

Job availability for pathologists, per the Pathology Outlines website (pathologyoutlines.com), has increased from approximately 300 pathology job positions in 2017 to approximately 700 in 2023. However, of 705 pathology jobs listed as of April 2023, only 5 (0.7%) had a job description mentioning that J-1 and/or H-1B visa holders were eligible.²⁶  Another popular job search website, Practice Link (PracticeLink Ltd), showed 148 pathology job positions as of April 2023, of which 2 (1.3%) mentioned they accepted J-1 and/or H-1B visa applicants.²⁷  Whether physicians with J-1 or H-1B visas are eligible for the other positions is currently unclear, making the application process cumbersome for both parties.

Census and population data show that approximately 25% of practicing physicians in the United States are non–US citizens.^8,10,12,28  Similarly, the Association of American Medical Colleges Physician Specialty Data Report established that approximately 31% (3761 of 12 180) of active pathologists in 2021 were IMGs.²⁹  In addition, physician workforce projections estimate that physician demand in the United States will grow faster than supply, with the number of unfilled physician positions ranging from 37 800 to 124 000 by the year 2034.¹  Given these estimates in addition to the growing number of pathology jobs and the continued presence of highly qualified non-US IMGs, efforts to improve non-US IMGs' access to pathology positions and retention of non-US IMGs in pathology should be enhanced. All US institutions, academic and nonacademic, that currently have or plan to have a department of pathology should increase awareness of the pathologist shortage and the rules and regulations that limit the hiring of non-US IMGs to address this shortage, and ideally, such institutions should actively educate policymakers to promote durable solutions to these issues. It is currently unknown how many highly qualified residents and fellows with J-1 visas are forced to leave after completing many years of advanced medical training in the United States and how many of them return after completing the 2-year home country residence requirement. It is up to the newer generation of pathologists to increase awareness of the vital importance of non-US IMG physician retention and find ways to mitigate the evolving physician shortage, whether through the modification of current regulations or the generation of new solutions.

Non-US IMGs continue to face visa-related barriers to securing residency positions in the United States and entering the US physician workforce. Reducing those barriers is 1 potential, at least partial solution to the physician shortage in the United States, which affects all specialty areas, including pathology. Academic and nonacademic institutions with departments of pathology should raise awareness of the barriers to entry of non-US IMGs into the pathologist workforce and advocate with policymakers to reduce such limitations.

Stephanie Deming, ELS, Research Medical Library, The University of Texas MD Anderson Cancer Center, assisted us with the editing of this manuscript.