[codebyaditya]

Fair point. To be clear we aren't saying wage should be the only rule, just that it's weird to see such a huge disconnect. Usually money talks.

Your "gateway" hunch is likely spot on. Most rural docs start on J-1 waivers (mandatory 3 years). If they actually stayed after that, we'd see way more H-1B conversions filed by those rural hospitals to keep them. Since the volume is so low, it suggests once the 3 years are up, they bail for the city. The wage premium just isn't enough to anchor them.