Highlights
- 85% of US adults support state licensure laws for internationally trained surgeons to address workforce shortages.
- 78% of respondents reported they would be less likely to personally select an internationally trained surgeon for their own procedure.
- 94.3% of the public supports mandatory disclosure of a surgeon’s training background as part of informed consent.
- 76.6% of respondents believe practice for these surgeons should be restricted to medically underserved areas.
Background: The Surgical Workforce Crisis and Regulatory Shifts
The United States is facing a looming physician shortage, with surgical specialties particularly vulnerable to workforce gaps. Traditionally, the pathway for internationally trained physicians to practice in the US has been rigid, requiring the completion of an Accreditation Council for Graduate Medical Education (ACGME)-accredited residency or fellowship, regardless of the clinician’s prior experience or expertise in their home country. This process often takes years and serves as a significant barrier to entry for highly skilled global talent.
In response to these shortages, several US states—most notably Tennessee, followed by others like Florida and Virginia—have recently enacted legislation to bypass the US residency requirement for qualified internationally trained physicians. These laws allow for licensure based on verified international training and clinical experience. However, this departure from long-standing licensure norms has sparked intense debate within the medical community and among the public regarding patient safety, technical competency, and the ethical implications of recruiting talent from other nations.
Study Design: Assessing the Pulse of the American Public
To understand how these legislative changes are perceived by the population they are intended to serve, Bohler and colleagues conducted a cross-sectional study in July 2025. The researchers utilized an online crowdsourcing platform (Amazon Mechanical Turk) to survey a diverse group of US adults. A total of 1270 initial responses were collected, with 1066 participants (83.9%) passing rigorous quality control measures, including attention checks and time-based screening.
The 21-item survey was designed to measure several key domains: general support for licensure laws, perceived training equivalence, personal comfort with receiving care, ethical concerns regarding international brain drain, and preferences for regulatory oversight. Data were analyzed with a focus on subgroup differences, particularly along the lines of sex and self-identified political orientation, using statistical methods such as χ2 testing to ensure validity.
Key Findings: A Dichotomy of Support and Hesitation
The results of the study present a striking dichotomy. On a macro level, the American public appears highly supportive of workforce expansion. Approximately 85% of the 1066 respondents supported state licensure laws for internationally trained surgeons. This support was largely driven by the belief that such laws would improve healthcare access (93%) and enhance the diversity of the surgical workforce (80.3%).
The Trust Gap in Personal Care
However, this broad policy support did not translate into personal clinical trust. When asked about their own healthcare choices, 78% of respondents stated they would be less likely to select an internationally trained surgeon for a personal surgical procedure. Furthermore, a significant majority (73.8%) did not view international surgical training as equivalent to the training provided in US-based ACGME-accredited programs. This suggests that while the public recognizes the systemic need for more surgeons, there remains a persistent skepticism regarding the technical standards of non-US training pathways.
Mandatory Disclosure and Transparency
Transparency emerged as a non-negotiable requirement for the public. An overwhelming 94.3% of participants supported the mandatory disclosure of a surgeon’s training background during the informed consent process. This finding indicates that patients view the geographic origin and nature of surgical training as a material fact essential to their medical decision-making.
Demographic and Political Divergence
The study also highlighted significant demographic variations in attitudes. Males (90.7%) and those identifying as conservative (89.9%) were statistically more likely to support the new licensure laws compared to their counterparts. Conversely, liberal-leaning respondents expressed higher levels of personal discomfort with receiving care from internationally trained surgeons (85.3%) and were more concerned with the ethical implications of these policies.
The Ethical Dilemma: Brain Drain and Global Equity
Beyond the clinical walls, the study touched on a sensitive geopolitical issue: the international brain drain. Approximately 70.8% of respondents expressed ethical concerns that the US policy of recruiting internationally trained surgeons might deplete the healthcare resources of other nations, particularly those in the developing world. Liberal respondents were notably more sensitive to this issue (82.4%) than conservatives. This highlights a complex ethical tension: while the US seeks to solve its own workforce crisis, it may inadvertently exacerbate healthcare disparities on a global scale.
The Policy Implications: Underserved Areas and Regulatory Oversight
The findings provide a clear roadmap for how the public believes these new laws should be implemented. A majority (76.6%) of respondents supported restricting the practice of internationally trained surgeons to medically underserved areas. This suggests that the public views these surgeons as a targeted solution for specific regional shortages rather than a general replacement for the existing domestic training pipeline.
From a regulatory standpoint, these results suggest that state medical boards must develop robust frameworks for verifying international credentials. The public’s insistence on disclosure and their skepticism toward training equivalence suggest that any perceived drop in surgical outcomes could lead to a rapid erosion of trust in the healthcare system.
Expert Commentary: Balancing Access with Technical Standards
Clinical leaders note that the technical nature of surgery makes this debate unique compared to primary care. In surgical fields, outcomes are often highly dependent on specific institutional protocols and technological familiarity. The public’s reluctance to personally receive care may reflect a sophisticated understanding that surgical excellence is not just about individual skill, but about integration into the specific standards of the US healthcare environment.
Furthermore, the high demand for disclosure underscores the necessity for hospitals to be proactive in how they credential and introduce internationally trained staff to their communities. If these surgeons are perceived as “second-tier” solutions for underserved populations, it could create a two-tiered system of surgical care that raises significant health equity concerns within the US.
Conclusion: Navigating the New Frontier of Surgical Licensure
The study by Bohler et al. provides a critical baseline for understanding the social contract between the medical profession and the public. While the US public is pragmatically supportive of legislative efforts to expand the surgical workforce, this support is heavily qualified. Patient autonomy, transparency, and geographic restrictions are key components of public acceptance.
As more states move toward these licensure models, policymakers must prioritize rigorous competency assessments and clear communication with the public. Addressing the “trust gap” will require more than just passing laws; it will require demonstrating that internationally trained surgeons can meet the high clinical and safety standards that the American public expects. Future research must track the clinical outcomes of these surgeons as they enter practice to determine if public concerns are reflected in patient safety data.
References
Bohler F, Noorani A, Selber JC, et al. Public Views on State Licensure of Internationally Trained Surgeons Without US Residency. JAMA Surg. Published online January 21, 2026. doi:10.1001/jamasurg.2025.6145.
