The Government’s WAR Against American Doctors FIRST
After earning a medical degree, who gets the residency, the citizen or the foreigner?
We tell our children to study hard. Get the education. Earn the degree. Prepare for a profession where they can make a difference. Suppose Johnny does all of that.
He graduates from medical school. He has the degree. But on the usual path toward independent medical practice, there is another essential step: postgraduate clinical training, usually through residency training. And without a residency selection, a student’s medical career is effectively on hold, as residency training is required to obtain a full medical license and practice independently.
So, now Johnny needs a residency. And that brings me back to the question we asked in my last article: When does the system give American applicants First Consideration? The ANSWER – it doesn’t. It rewards Foreign Trained Physicians with VISA preferences to overcome Medicare Reimbursement CAPS on U.S. Doctors.
A controversy involving Rochester General Hospital in New York brought that question into sharp focus. A viral post alleged that 80 of 82 resident physicians were foreign-trained working under H‑1B or J‑1 VISAS, leaving only two positions for Americans.
That is a serious allegation. It also remains unverified. Medical-school rosters do not establish citizenship or VISA status, and the hospital’s published response did not provide that breakdown. Still, the questions deserve answers.
How many American applicants applied? How many were interviewed? How were applicants selected? And what role did VISA sponsorship play?
Before we can answer those questions honestly, we need to understand three things: 1. How residency selection works; 2. How H‑1B and J‑1 differ; and 3. What the numbers actually tell us.
A country concerned about having enough doctors should also be concerned about whether qualified Americans have a fair opportunity to complete their training.
WHO GETS THE RESIDENCY — AND HOW?
Before we decide whether Johnny was passed over, we need to understand how applicants and residency programs find each other.
Many positions are filled through the National Resident Matching Program (NRMP), commonly called “the Match.” Applicants apply to programs and interviews. Then both sides make choices: applicants rank the programs where they want to train, and programs rank the applicants they are willing to train. A computer algorithm compares those lists. It starts with the applicant’s preferences and attempts to place that person in the highest-ranked program that can accept them under the matching rules. Programs’ rankings and available positions also determine the outcome.
So, the questions begin before the computer runs: Who received an interview? What qualifications did the program value? Who was ranked — and who was left off the list? A hospital’s final roster only tells us who arrived. By itself, it does not tell us why another applicant did not.
There is another part of Johnny’s predicament: how residency training is funded. The Balanced Budget Act of 1997 established hospital-specific limits (CAPS) on the number of American residents Medicare would support to help prevent an oversupply of doctors, generally based on each hospital’s 1996 training levels. Hospitals can train residents above those limits, but must cover the additional costs through other resources. The 1997 Act doesn’t affect H‑1B and J‑1 sponsored foreign-trained residency doctors. But they raise a separate question that deserves attention alongside fair selection: If America post-1997 now needs more doctors, why aren’t we supporting enough opportunities to train American ones?
“AMERICAN” AND “AMERICAN-TRAINED” – NOT THE SAME THING
This distinction stopped me, because it changes how we read the numbers. An international medical graduate, or IMG, attended medical school outside the United States under the applicable reporting definitions. That label describes an educational background. It does not, by itself, establish citizenship.
An American citizen who attended medical school abroad can be an IMG. A noncitizen IMG may be a permanent resident who does not need employer VISA sponsorship, or someone who does. But the NRMP reports these groups separately — and even distinguishes outcomes for noncitizen IMGs who require sponsorship from those who do not. A foreign medical-school name on a roster does not prove that an American lost a position to a VISA holder.
That is Why the Rochester Citizenship and VISA Breakdown Matters.
WHAT DO THE NATIONAL NUMBERS SHOW?
The 2026 results provide context we cannot leave out:
| Applicant group | Matched to a first-year position | Placement through the Match and supplemental offers |
| Seniors at U.S. MD schools | 93.5% | 97.8% |
| Seniors at U.S. DO schools | 93.2% | 98.5% |
| U.S.-citizen international medical graduates | 70.0% | 77.8% |
| Non-U.S.-citizen international medical graduates | 56.4% | 59.9% |
These figures describe active applicants in each group. The supplemental process — called SOAP — offers eligible unmatched applicants another opportunity to obtain an unfilled position. But the U.S. MD and DO rows describe school enrollment, not citizenship; they also concern graduating seniors, rather than everyone who graduated in a previous year.
Nationally, seniors at U.S. medical schools had substantially higher placement rates than either IMG group. That deserves to be stated plainly. Those national results cannot explain every hospital’s decision or every applicant’s experience. Nor should we overlook the American citizens who studied abroad and faced substantially lower placement rates. Which brings us to the next question:
When a residency program accepts a physician who needs VISA sponsorship, what do H‑1B and J‑1 actually permit — and what obligations come with them?
TWO VISA ROUTES — WITH DIFFERENT RULES
H‑1B and J‑1 often appear together in headlines. But they serve different purposes, carry different obligations, and provide targeted preferences for foreign doctors only.
J‑1: COMING HERE FOR MEDICAL TRAINING
The J‑1 physician program is an educational exchange. ECFMG, a division of Intealth, sponsors physicians participating in approved U.S. clinical training programs. The hospital provides the training; ECFMG provides the visa sponsorship.
Physicians must provide a Statement of Need from the health ministry of their country of citizenship or most recent legal permanent residence. Sponsorship generally lasts no longer than seven years and authorizes specified training activities. These physicians are also subject to a two-year home-country physical-presence requirement before becoming eligible for certain other U.S. immigration statuses, unless they obtain a waiver from the two-year presence requirement. And that waiver is an important part of the story…
One route, known as Conrad 30, allows qualifying physicians to obtain a waiver tied to a commitment to practice medicine for at least three years serving underserved communities in the U.S. Physicians using this route generally fulfill that service in H‑1B status. So, a physician may arrive for temporary training and later qualify to stay and work under a separate legal provision. That “preference” is now built into the law.
H‑1B: EMPLOYER-SPONSORED WORK
H‑1B is the specialty-occupation employment category we examined in the previous article. It is also used for qualifying for actual U.S. hospital physician positions, including some residency and fellowship positions.
Employers have wage obligations. They must pay at least the actual wage for comparable employees with similar qualifications and experience, or the applicable prevailing wage — whichever is higher. A VISA does not give an employer permission to ignore those wage protections.
Yet wage protection and priority for American applicants are different questions. For most H‑1B employers, the program does not impose a general requirement to recruit U.S. workers first. Additional recruitment and hiring obligations ONLY apply to certain H‑1B-dependent employers and willful violators, subject to exemptions again.
And that brings us back to Johnny…
The existence of an H‑1B or J-1 approval or waiver does not, by itself, tell us that no qualified American was available. And the presence of a VISA holder does not, by itself, prove that an American was improperly rejected. To answer that question, we need evidence about the particular employer’s recruitment and selection decisions.
If a hospital cites a physician shortage, we should ask it to explain the shortage it is trying to fill: which specialty, which community, and which positions? Then we should ask how qualified American applicants were considered, and whether Medicare reimbursement CAPS mattered.
Those are questions a serious discussion of our medical workforce should be able to address.
HOW MUCH OF OUR PHYSICIAN WORKFORCE IS FOREIGN-BORN?
The Migration Policy Institute’s analysis of 2021 Census data found that 26% of U.S. physicians and surgeons were foreign-born — approximately one in four. That includes naturalized American citizens; it does not mean one in four doctors holds a temporary work VISA.
The share is higher in some fields. An American Board of Internal Medicine study released in August 2026 found that 47.2% of the physicians studied in internal medicine and its subspecialties were born abroad, including doctors educated at U.S. medical schools.
These figures show how substantial a role physicians born abroad play in American medicine. They also reinforce why we must distinguish birthplace, citizenship, medical education, and VISA status before drawing conclusions.
The size of that workforce deserves attention. Whether a particular hospital fairly considered American applicants still requires evidence about its decisions.
ROCHESTER: SHOW US HOW THE DECISIONS WERE MADE
The Rochester Hospital has defended the qualifications of its physicians and cited workforce shortages. Its published response did not provide the citizenship and VISA breakdown needed to evaluate the allegation.
A useful answer would identify:
- The group being counted. Which hospital, residency programs, training years, and dates make up the reported 82?
- The actual citizenship and immigration categories. How many were U.S. citizens, permanent residents, H‑1B holders, J‑1 holders, or in another category?
- The applicant pool and selection criteria. How many qualified American applicants applied, were interviewed, and were ranked? What qualifications guided those decisions?
- The workforce need. Which shortages were these positions intended to address? Were shortages created by Medicare reimbursement CAP policies?
These questions can be addressed through aggregate information without publishing individual applicants’ private records. The answers may support the hospital’s explanation. Or they may reveal problems. We should be prepared to follow the evidence either way; but Anti-American VISA and Medicare Policies MUST END!
JOHNNY DESERVES AN ANSWER. SO DO THE PATIENTS.
I began this inquiry asking when the American applicant gets First Consideration. What I found is a system in which medical education, residency selection, 1997 Medicare CAPS, immigration status, and workforce needs intersect, to deny that First Consideration. And I found Our Own Government is Behind This, and similar programs, including the Heartland VISA Program for skilled immigrants.
An American who attended medical school abroad is still an American. A physician working here lawfully on a VISA deserves to be judged by qualifications and conduct alone. And a Citizen applicant who did not obtain a residency deserves an honest examination of the barriers, without a promise that every rejection proves wrongdoing.
We can value the care international physicians provide but still insist on fair opportunities for qualified Americans, FIRST.
That means asking hospitals to explain their selection practices, asking government policymakers whether the current restricted training system meets the country’s current needs, and examining whether existing worker protections are doing their job.
For Johnny, this is His Future. For a patient waiting to see a doctor, it is Access to Care.
Both deserve a system we can understand — and can hold accountable.
Let’s Get the Numbers, Examine the Decisions, And Let the Evidence Tell Us What Needs to Change Before We Lose Anymore Dr. Johnnys.
By Linda S. Brickman
©2026 Linda S. Brickman. All Rights Reserved.
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