The current U.S. medical education and health care systems undeniably benefit from the immigration of talented international medical graduates (IMGs). Many of my favorite teachers, residents, and colleagues have been IMGs. However, the longstanding U.S. reliance on immigrant physicians raises questions about what policies best support both domestic and international priorities moving forward.
Beyond medicine, the immigration of talented scientists and engineers has also sparked recent public debate. Elon Musk recently declared that “bringing in via legal immigration the top 0.1 percent of engineering talent” is “essential for America to keep winning.” In fact, over half of doctorate degrees awarded in the U.S. go to foreign students, many of whom eventually gain permanent resident status.
In health care, IMGs constitute about 25 percent of practicing physicians in the U.S., playing a critical role in maintaining the system’s functionality. Yet, this raises the primary question: Why is the U.S.—of all countries—unable to train enough physicians to meet its needs, especially when there are plenty of medical school applicants, and ironically, countries with fewer resources than us appear to be producing an “excess” of doctors for our consumption?
This isn’t a new problem, so why can’t we fix it? In short, the U.S. Congress—maybe. The Resident Physician Shortage Reduction Act of 2023—still “sitting on Capitol Hill”—proposed expanding Medicare-funded US residency positions by 2,000 annually over seven years (a total of 14,000 new positions by 2031). This bill would not obviously be a total solution to our thirst for IMGs since about one-quarter of U.S. residency spots are already being filled by IMGs. Thus, we also need more U.S. medical school graduates.
In any case, I will set aside the IMG issue in order to focus this discussion on the broader (philosophical) implications of the continuous extraction of global talent for the benefit of the U.S. That is, although adopting Musk’s patriotic-sounding “keep winning” philosophy may help the U.S. maintain its economic and military dominance, it must come at a substantial cost to the countries that are consistently losing their brightest minds. It raises a fundamental question: Is global economic growth a “zero-sum” game? Must other nations “lose” in order for us to “keep winning”? Are we acting out a global version of social Darwinism in which global wealth inequality is a justified (or necessary) consequence of the pure pursuit of excellence?
Beyond that, how fair is it for the U.S. to judge other nations for poor economic growth and political instability when we extend open arms to their most promising leaders in science, engineering, and medicine? Countries struggling with political and economic instability face a vicious cycle. To retain experts, they need stability and infrastructure, but achieving these goals requires the very experts who are leaving. This “brain drain” also contributes to broader instability, likely increasing rates of immigration to the U.S. and other developed countries. In this respect, are we partially responsible for the immigration challenges we lament? Would a more supportive global perspective allow other countries to “win” as well, or is that an unacceptable threat to U.S. dominance?
During the COVID-19 pandemic, some IMG physicians that I know organized fundraising efforts to support their home countries. While commendable, the effort also highlighted a critical question: How might these countries have responded differently to the pandemic if thousands of their best doctors hadn’t been lured away by the attractive lifestyle promised by the U.S.? The investments these nations make in training professionals are lost when those individuals emigrate, leading to weakened leadership, diminished research capacity, and perhaps most importantly, fewer role models for the next generation.
To be fair, not all foreign professionals who study and train in the U.S. remain in the U.S. Many return home with advanced knowledge (gifted from us—so to speak) for the benefit of their countries of origin. Perhaps denying these learning opportunities to the world’s best and brightest would, in fact, inflict more harm globally than welcoming them. That is hard to judge.
I think the question still remains: Can we move toward a mindset where prosperity is not a zero-sum game? A decrease in global wealth inequality would certainly require a selfless, collective effort, but could certainly soften immigration pressures and improve living conditions in many countries. As we consider the policies and priorities shaping immigration, it’s worth reflecting on whether our current approach aligns with a vision of mutual global success or simply reinforces inequality (and instability) for the sake of maintaining dominance.
In health care, at least, the U.S. Congress can start by making it a budget priority to train enough of our own doctors, thus reducing our dependence on IMGs while allowing other countries to flourish under the leadership of their best and brightest in medicine.
David M. Mitchell is a hospitalist.
