Foreign medical graduates; Internship and residency; Emigration and immigration; Health workforce; Education, medical, graduate; Pakistan

Each year, the Pakistan Medical and Dental Council (PM&DC) announces how many Pakistani graduates have secured residency positions in the United States (US). In 2025, the figure was 1,061, the highest ever recorded, and the council described it as evidence of the strength of Pakistani medical education [1]. In 2026, more than 1,400 placements were reported [2]. These are real achievements, earned by young doctors who have studied for years alongside house jobs and night calls. However, the celebration sits uneasily beside another number. An analysis of Bureau of Emigration and Overseas Employment records by Gallup Pakistan showed that nearly 4,000 doctors left the country in 2025, the largest annual outflow on record, after nearly three decades in which departures remained in the hundreds [3].

Doctors have always left Pakistan, and they will go on leaving. More than 31,000 doctors emigrated through official channels between 1971 and 2022 [4], and surveys of final-year students and house officers have long shown that many plan to train abroad, citing the career value of a foreign residency, poor pay, and scarce jobs at home [5]. The argument here is not that this movement should be stopped. The problem is that Pakistan and the main destination countries both treat the move abroad as a private project. Its costs and risks fall almost entirely on the individual graduate, while the institutions that benefit claim the successes and accept no responsibility for the failures. That arrangement is becoming more difficult to defend because the obstacles have risen sharply in the past two years.

The first obstacle is money. Before a Pakistani graduate can submit a single residency application, the fees charged by the Educational Commission for Foreign Medical Graduates for the certification application, credential verification, the clinical and communication skills pathway, and the application token exceed US$1,900, and a further US$590 is due for J-1 visa sponsorship once a position is secured [6]. These sums exclude the fees for the two United States Medical Licensing Examination (USMLE) Step examinations, preparation material, travel, and the months of unpaid study that most candidates need, and all of it is paid in dollars from rupee incomes. The informal requirements cost more. Programs favor applicants with US clinical experience, yet few teaching hospitals accept international graduates for hands-on rotations, and those that do often charge substantial fees, so such experience is available mainly to those with family money [7]. The process therefore filters on wealth well before it filters on merit, and there is no systematic record of how many capable graduates abandon the attempt at this stage.

The second obstacle is the visa itself. In the 2026 Main Residency Match, the match rate for non-US-citizen international medical graduates (IMGs) fell to 56.4%, the lowest in five years, compared with 93.5% for senior students of US medical schools. The gap within the foreign-born group is more revealing: applicants who needed visa sponsorship matched at 54.4%, whereas foreign-born permanent residents matched at 67.9% [8]. The National Resident Matching Program (NRMP) itself tied this pattern to recent changes in federal immigration policy [8]. Needing a visa now carries a measurable penalty of its own, and nearly every Pakistani applicant needs one.

Matching no longer settles the matter either. In late May 2025, weeks before residencies began, the US Department of State paused interview scheduling for exchange-visitor visas, including those for J-1 physicians; the pause was lifted in mid-June, and the NRMP asked hospitals to consider delayed starts or one-year deferrals for affected IMGs [9]. A presidential proclamation in September 2025 imposed a US$100,000 fee on new H-1B petitions, the visa category that hospitals use to employ many international physicians. A federal district court vacated the fee in June 2026, but an appeal is expected [10]. From January 2026, immigrant visa issuance was suspended for nationals of a long list of countries, Pakistan among them [11], and the American College of Physicians warned that immigration adjudication pauses could disrupt H-1B visa extensions, changes of status, and J-1 waiver processing for IMGs already practicing in the United States [12]. A graduate in Lahore deciding today whether to commit two years and several thousand dollars to this route cannot know which of these rules will apply by the time she arrives.

The United Kingdom (UK), the other major destination, has also narrowed its entry routes. The Medical Training (Prioritisation) Act 2026, which received Royal Assent on March 5, 2026, gives graduates of UK medical schools priority for foundation and specialty training posts [13]. Some international doctors with prior UK training or settled status are protected, but a Pakistani graduate who passed the licensing tests under the old rules and is working in a nontraining post now competes behind a statutory queue. UK data published in 2025 showed that 4,880 internationally qualified doctors left UK practice in 2024, a 26% increase from the previous year [14]. Pakistan's own status adds a paradox. Because the country appears on the World Health Organization health workforce support and safeguards list, UK employers may not actively recruit its doctors [15,16]. The list rightly protects fragile health systems, and it places no limit on individuals who apply on their own initiative [17]. In practice, however, Pakistani doctors reach the UK through self-funded, unstructured applications rather than through any managed scheme.

Those who do pass through face a further problem that is often misread. A national data-linkage study of UK trainees found that international graduates were more likely than UK graduates to receive a less satisfactory outcome at their annual progression review, but those who had scored in the top twelfth of the licensing test performed no differently from UK graduates [18]. Gaps of this kind are easily read as proof of weaker training. A systematic review of 46 studies, however, points to unmet needs in acculturation, communication, familiarity with health system norms, and exposure to bias, all of which targeted orientation can address [19]. A review of the US experience describes the same pattern and adds the financial strain and isolation of trainees who arrive without family support [7]. The deficit lies in the transition, and transitions can be supported.

What would it mean to treat this as policy rather than personal fortune? For Pakistan, three steps follow. First, the measure of success should change. Match counts reward departure; what matters to the country is how many of these doctors return, keep clinical or academic links, or help train the next generation at home, a figure that is not routinely reported. Medical regulators and provincial health departments could track it through simple follow-up of registrants. Second, the government should use the room that the international framework already offers. The safeguards list does not forbid migration; it recommends that the movement of health workers from listed countries take place under government-to-government agreements that set out benefits for both sides [20]. Pakistan could negotiate such agreements with the UK, Ireland, and the Gulf states, tying structured training posts abroad to defined return or service arrangements and transparent costs. Third, return must become a credible option. If a physician trained in Chicago or Manchester expects lengthy uncertainty over the recognition of foreign qualifications and the availability of posts at home, return will not happen, regardless of policy documents. In addition, medical universities could replace the commercial market in paid observerships and coaching with free, accurate guidance so that the route abroad depends less on family wealth.

Destination countries also carry obligations. Internationally trained doctors make up approximately one-quarter of US physicians and approximately 42% of the UK medical workforce [12,14]. Changing the rules for people already partway through a multiyear pathway, often with only weeks of notice, transfers the cost of political uncertainty to individual trainees. At a minimum, such changes should come with transition periods, protection for applicants already in the pipeline, and exemptions for physicians where the stated aim of a policy has nothing to do with medical training.

Pakistani doctors will continue to train abroad. For many, it is the best available route to the training they want, and some of the finest clinicians this country has produced have taken it. The real question is whether that movement remains something that happens to the health system—celebrated in press releases and ignored in planning—or becomes something the system manages deliberately. Applause costs nothing. A policy that shares the burden, tracks outcomes, and makes return a genuine option would cost something, and it would be worth far more.

IMG: International medical graduate

NRMP: National Resident Matching Program

PM&DC: Pakistan Medical and Dental Council

UK: United Kingdom 

US: United States

USMLE: United States Medical Licensing Examination

The author wrote and revised the manuscript, and approved the final version.

During the preparation of this work, the author used OpenAI's GPT-6 Astra to assist with language refinement, including improvements in clarity, grammar, and overall readability of the manuscript. After using this tool, the author reviewed and edited the content as needed and takes full responsibility for the content of the published article.

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The author declares no conflicts of interest.

© 2026 The Author. This is an open access article distributed under the terms of the Creative Commons Attribution (CC BY) License.