"Empty Places…People Could Not See": Structural Barriers Faced by US-Based International Medical Graduates

Purpose: International medical graduates (IMGs) have long sustained the US healthcare system. In the US, 25% of practicing physicians are IMGs, who are pivotal for delivering primary and preventive care and for tending to first-generation immigrants. Despite their contributions, studies primarily have focused on individual challenges and difficulties of IMGs. In contrast, structural barriers-and their impact on IMGs' private lives and emotional wellbeing-are rarely discussed. Using the example of Asian IMGs in the US, we explored structural barriers that complicate everyday thriving, including family wellbeing, work conditions, and emotional life. Method: We conducted a constructivist, qualitative interview study with 20 IMG physicians (60% female) in 2023. We purposefully sampled across multiple specialties, clinical settings, and geographic areas. The average time serving as an attending was 11.8 years. We recorded and transcribed semi-structured interviews, which lasted 45-60 minutes. With attention to IMGs' positionality, we applied reflexive thematic analysis and Burgess-Proctor's strategies for engaging with and empowering participants. We also drew on Ahmed's theory of the politics of emotions to inform our interpretation. Results: IMGs described interconnected structural barriers rooted in the US visa system, including financial hardship, prolonged family separation, and sponsorship-dependent career precarity. Beyond these constraints, participants also encountered institutional selection bias and professional gatekeeping, including an invisible ceiling, tokenization, and limited recognition of IMG status within broader diversity discourse. While expressing gratitude for US career opportunities, participants reported a significant emotional toll characterized by guilt and shame tied to outsider positioning and pressures to justify their legitimacy in US training. Discussion: Structural barriers have a profound impact on IMGs' relational and emotional lives. What might appear as a personal hardship-such as family separation-is in fact a consequence of structurally imposed constraints. Participants pointed to concrete areas where institutional practices could change, including formalized mentorship structures, stronger institutional accountability, more explicit inclusion practices, and policy advocacy. Addressing these inequities will require institutional engagement, with implications for sustaining the US physician workforce.