About one fourth of practicing physicians in the United States graduated from medical schools in other countries. While much attention has been given to their role in the physician workforce, less attention has been given to the impact international medical graduates' (IMG) status might have on clinical practice. This study considers how IMG status affects physician decision-making, particularly whether knowledge of a specialist's IMG status impacts a primary care physician's patterns of referring patients to that specialist. Researchers drew a sample of over 1,000 primary care physicians from the American Medical Association Physician's Professional Data. Using varying vignettes of clinical cases, physicians were asked, via mail survey, which patients required referral to a specialist. They were then asked to choose the appropriate specialist from among five choices with characteristics that varied by U.S. medical graduate (USMG) vs. IMG—age, race, sex and referral characteristics. Researchers measured the decision to refer to an international versus U.S. medical graduate specialist. Results indicated that respondents were significantly more likely to refer to a USMG compared with an IMG. It is possible that due to negative views of IMGs, a patient could be referred to a USMG with inferior clinical skills rather than an IMG with superior clinical skills. IMGs may therefore choose to practice in areas in which they are more likely to be included in referral networks. These responses to bias could lead to maldistribution of physician expertise, a practice of concern in this increasingly global and diverse society.