Agreement: I AgreeBody: Dear Editor, As two family medicine researchers in Spain, we read Dyer’s report on the new $100 000 filing fee for H-1B petitions with concern and empathy for colleagues and patients who may be affected (1). Although the stated target appears to be the tech sector, US primary care, rural hospitals, and academic centers also rely on internationally trained physicians. Empirical data show that H-1B physicians represent a measurable (if numerically modest) segment of the workforce and are concentrated in particular states and employers, while international medical graduates (IMGs) constitute a substantial share of US family medicine and often staff communities with lower incomes (2,3). Any policy that abruptly raises transaction costs on physician hiring risks destabilizing teams and increasing vacancies where recruitment is already fragile. From a patient-care perspective, the debate should not be framed around doubts about IMG quality. In a national study of over 1.2 million admissions, patients treated by IMGs had slightly lower 30-day mortality than those treated by US-trained internists working in the same hospitals (4). At the same time, two systematic reviews link higher continuity of doctor-patient relationships to lower mortality, an outcome particularly relevant to community-based care (5,6). Policies that interrupt the inflow of physicians to rural clinics and safety-net systems may erode continuity and compound access problems, even if temporarily. If the administration pursues the fee, we encourage a transparent, pre-specified blanket exemption for physicians (including residents, fellows, and clinician-scientists) under the “national interest” clause, rather than case-by-case adjudication that would add administrative friction and uncertainty. Where H-1B pathways tighten, hospitals will pivot to J-1 sponsorship and the Conrad-30 waiver; yet recent national US data suggest the program’s mix has shifted away from primary care and rural placements (7). Guardrails that prioritize shortage specialties and underserved geographies would better align with population needs (8). Finally, this episode offers a chance to learn. A time-limited policy with prospective evaluation (tracking vacancy duration, service reductions, and continuity metrics in Health Professional Shortage Areas) could inform future workforce planning. As outsiders who grapple with similar distributional challenges in Europe (9), we do not claim easy solutions (10). But the US experience shows that stable, predictable immigration rules that value clinical service and training are compatible with quality and safety. Grounding any revisions in evidence and careful monitoring would help protect patients while addressing legitimate policy aims. Sincerely, MD. Rebeca Tenajas Master in Medicina Clínica, Family Medicine Department, Arroyomolinos Community Health Centre, Spain ORCID: 0000-0001-8815-7341 Dr. David Miraut Independent Researcher, Former Lecturer at Rey Juan Carlos University, Spain ORCID: 0000-0003-1648-5308 References: 1. Dyer O. What does Trump’s H-1B visa ban mean for doctors in the US? BMJ. 2025 Sept 30;390:r2055. 2. Kahn PA, Gardin TM. Distribution of Physicians With H-1B Visas By State and Sponsoring Employer. JAMA. 2017 June 6;317(21):2235–7. 3. Duvivier RJ, Wiley E, Boulet JR. Supply, distribution and characteristics of international medical graduates in family medicine in the United States: a cross-sectional study. BMC Fam Pract. 2019 Mar 30;20(1):47. 4. Tsugawa Y, Jena AB, Orav EJ, Jha AK. Quality of care delivered by general internists in US hospitals who graduated from foreign versus US medical schools: observational study. BMJ [Internet]. 2017 Feb 3 [cited 2025 Sept 30];356(8092). Available from: https://www.bmj.com/content/356/bmj.j273 5. Baker R, Freeman GK, Haggerty JL, Bankart MJ, Nockels KH. Primary medical care continuity and patient mortality: a systematic review. Br J Gen Pract. 2020 Sept 1;70(698):e600–11. 6. Gray DJP, Sidaway-Lee K, White E, Thorne A, Evans PH. Continuity of care with doctors—a matter of life and death? A systematic review of continuity of care and mortality. BMJ Open. 2018 June 1;8(6):e021161. 7. Ramesh T, Brotherton SE, Wozniak GD, Yu H. Evaluation of the Conrad 30 Waiver Program’s Success in Attracting International Medical Graduates to Underserved Areas. JAMA Health Forum. 2023 July 28;4(7):e232021. 8. Tenajas R, Miraut D. Comprehensive Family Medicine at Risk? Lessons from Ontario and Implications for Spain. Ann Fam Med. 2025 July 5;23(3):eLetter. 9. Tenajas R, Miraut D. A Shared Struggle: The Recruitment and Retention of Family Doctors in Deprived Areas of Japan and Spain. Ann Fam Med. 2024 Sept 30;22(5):eLetter. 10. Tenajas R, Miraut D. Primary Care Challenges and Commitments Across Different Health Systems. Ann Fam Med. 2025 Apr 27;22(2):eLetter. No competing Interests: YesThe following competing Interests: Electronic Publication Date: Tuesday, September 30, 2025 - 20:18AI use: Yes I have used AIHighwire Comment Subject: What does Trump’s H-1B visa ban mean for doctors in the US?AI use details: We would like to disclose that artificial intelligence tools were used to assist in translating portions of this rapid response from Spanish into English, and refining its written style.Workflow State: ReleasedFull Title: International Medical Graduates, Continuity of Care, and the Impact of H-1B Restrictions Highwire Comment Response to: What does Trump’s H-1B visa ban mean for doctors in the US?Check this box if you would like your letter to appear anonymously:: Last Name: TenajasFirst name and middle initial: RebecaEmail: rebeca.tenajas@salud.madrid.orgAddress: Avenida de la Unión Europea n. 50.Occupation: Medical Doctor, Master in Medicina ClínicaOther Authors: David Miraut. Independent Researcher.Affiliation: Family Medicine Department, Arroyomolinos Community Health Centre, SpainBMJ: Additional Article Info: Rapid response