Nearly 95% of US adults said a surgeon's international training background should be disclosed as part of informed consent, according to a study published in JAMA Surgery.
Public support for state laws permitting internationally trained surgeons to practice in the US without completing US residency training was substantial, although this support coexisted with reluctance to personally receive care and persistent concerns about training equivalence and ethics. In a national survey of 1,066 US adults, 85% supported these licensure laws, 93% believed they would improve access to care, and 80% anticipated increased diversity within the surgical workforce. However, 78% reported they would be less likely to select an internationally trained surgeon for their own surgery, and 74% did not consider international surgical training equivalent to US-based training. The study represents the first primary data on public perceptions of these recently enacted licensure laws.
The researchers conducted a cross-sectional survey in July 2025 using Amazon Mechanical Turk to examine public perceptions of state laws permitting internationally trained surgeons to practice without US residency training. Eligibility criteria required participants to be US-based adults with a human intelligence task approval rating of at least 95% across 100 or more prior tasks to support data quality. A 21-item questionnaire was administered through Qualtrics and incorporated attention checks, definitional comprehension items clarifying that internationally trained surgeons completed all surgical training outside the US, and time-based screening to exclude inattentive responses. Survey domains included support for licensure laws, perceived implications for access and diversity, ethical concerns related to international brain drain, perceptions of training equivalence, comfort with receiving care, hospital trust, and preferences for regulatory oversight. Analyses included descriptive statistics and chi-square testing stratified by sex and self-identified political views, with statistical significance defined as P less than .05.
The findings showed strong support for licensure laws despite reluctance to personally receive care from internationally trained surgeons. "The public seems to endorse these laws for the benefit of underserved communities yet remain hesitant to trust internationally trained surgeons with their own personal care," noted Forrest Bohler, BS, of the Division of Plastic and Reconstructive Surgery at Corewell Health East William Beaumont University Hospital in Royal Oak, Michigan, and colleagues.
Ethical concerns were common, with 71% of respondents expressing concern about potential international brain drain from countries that invested public resources in training surgeons. Nearly all respondents, 94%, supported mandatory disclosure of a surgeon's training background as part of the informed consent process, and 77% favored restricting practice by internationally trained surgeons to underserved areas. More than half of respondents indicated that state medical licensing boards, rather than legislatures or hospitals, should oversee regulation of these licensure pathways.
Political affiliation and sex influenced perceptions. Male respondents (91%) were more likely than female respondents (77%) to support the licensure laws. Respondents who identified as conservative (90%) were more supportive than those who identified as liberal (81%). However, respondents who identified as liberal were more likely to express ethical concerns about brain drain (82% vs 70%) and to report discomfort with receiving care from an internationally trained surgeon (85% vs 79%). Among respondents who indicated their assessment of training equivalence depended on the country, Canada was most frequently cited as having training comparable to US standards, followed by the United Kingdom, with Australia and Germany tied for third.
Attitudes toward hospital trust were mixed. Among respondents, 43% reported they would have decreased trust in a hospital employing internationally trained surgeons, 28% reported increased trust, and 29% reported no difference.
There were several limitations in the study. The respondent sample skewed younger, with a median age of 33 years, and was largely insured and well educated, which may limit generalizability to older adults and populations most affected by surgical access shortages. Use of an online crowdsourcing platform introduced self-selection bias and likely underrepresentation of respondents with lower educational attainment. Geographic identifiers were not collected, precluding analysis of differences between respondents living in states with enacted licensure laws and those without. Additionally, survey findings reflected perceptions rather than clinical outcomes, and the licensure laws had not yet been fully implemented at the time of data collection.
The researchers reported no conflicts of interest.
Source: JAMA Surgery