In recent years, several U.S. states have implemented laws that allow certain groups of international medical graduates (IMGs) to bypass traditional residency requirements before independently practicing medicine in the U.S. This development is seen as a response to both physician shortages—particularly in rural and underserved areas—and the various challenges faced by IMGs in securing U.S. residency positions.
The new laws differ by state, but generally offer alternative pathways to licensure, aiming to address workforce gaps while reshaping the landscape for foreign-trained physicians in the U.S.
This post is meant to shed some light on what these changes mean for IMGs who want to practice medicine in the U.S. To place our discussion in context, let’s begin by looking at the difficulties IMGs have traditionally faced when securing a U.S. residency position.
Challenges for IMGs to Practice in the U.S.
Traditionally, it’s been difficult for IMGs to obtain licensure in the U.S. due to the requirement that they complete a U.S. residency, even if they’ve already completed extensive training abroad. U.S. residency programs are highly competitive, with a limited number of spots, and IMGs are often less likely to secure a coveted spot compared to U.S. medical graduates.
Additionally, IMGs must pass U.S. licensing exams, navigate visa issues, and meet state-specific requirements, all of which add significant time and cost to the challenge of gaining licensure in the U.S.
Loosening Residency Requirements
Recent trends show a shift toward loosening residency requirements for IMGs. Several states have passed laws that allow IMGs to work at healthcare facilities associated with accredited residency programs under provisional licenses. After completing a two-year provisional period, IMGs can apply for unrestricted medical licenses.
This change bypasses the need for completing a competitive U.S. residency program, providing IMGs with a more direct path to licensure. While there are many who oppose the loosening of residency requirements for doctors educated outside the U.S., it seems to be gaining momentum.
The Legislative Trend Moving Forward
On April 4th, 2023, the Tennessee legislature passed TN Senate Bill 1451 to reduce residency requirements for IMGs. Following Tennessee, Illinois passed similar legislation in September 2023, allowing IMGs to obtain a provisional license under supervision for two years. Other states, such as Florida and Virginia, are on the verge of passing comparable laws.
And they aren’t alone. The following states have also taken steps to shorten residency requirements or establish temporary licensure pathways for IMGs:
- Alabama has reduced residency training for IMGs from 3 years to 2 years.
- Colorado requires only 1 year of residency for IMGs to apply for licensure.
- Idaho allows IMGs to obtain temporary licensure if they’re forcibly displaced and plan to work in underserved areas after residency.
- Washington offers a temporary 2-year license to IMGs who’ve been state residents for at least a year, with the option for renewal.
Some states listed above mandate that if licensure is obtained through bypassing traditional residency training, then IMGs are required to work in medically underserved areas.
Overall, these laws either eliminate or reduce residency requirements for IMGs who meet certain criteria.
Many other states such as Nevada, Iowa, Missouri, Vermont, and Wisconsin are also considering legislation that would offer provisional or temporary licensure pathways for IMGs. The evolving nature of this legislative movement suggests that more states could follow suit, especially in regions facing severe physician shortages.
How will this affect the landscape of U.S. healthcare for IMGs?
The introduction of these laws marks a significant shift in how residency and medical training is traditionally viewed in the U.S. medical system. Residency has been the primary training period for medical graduates to gain hands-on experience, didactics, and formative feedback before practicing independently.
For IMGs, who often already have years of medical training and experience in their home countries, securing a U.S. residency position has historically been a major barrier, often viewed by many as unnecessary. By allowing IMGs to bypass or reduce residency requirements, states like Tennessee, Illinois, and others are creating alternative licensure pathways to alleviate the shortage of physicians in these areas.
These pathways, in many cases, focus on supervised practice through provisional licensure, allowing IMGs to work in U.S. healthcare settings without completing a U.S. residency. By reducing residency requirements, states are providing IMGs with a faster, more direct route to licensure, especially in areas where healthcare needs are more urgent.
Long story short, these new laws reduce residency requirements for qualifying IMGs, and allow them to enter U.S. healthcare systems more easily so they can help in areas with critical physician shortages.
Who qualifies? And what are the educational and licensure requirements?
To qualify for these new licensure pathways, IMGs must meet several stringent requirements. While the specifics vary by state, qualifications typically include:
1. Legal Authorization to Work in the U.S:
IMGs must have a valid work visa or permanent residency. This includes securing their own immigration status, as states do not facilitate visas.
2. Certification by the Educational Commission for Foreign Medical Graduates (ECFMG):
The ECFMG certification verifies that the IMG’s medical education meets U.S. standards. This certification is crucial for both applying to residency and pursuing these alternative licensure pathways.
3. Passing the U.S. Medical Licensing Exams (USMLE):
IMGs must pass USMLE Step exams, which are the same ones taken by U.S. MD graduates (COMLEX for DO counterparts). These exams are regarded as very important when it comes to demonstrating U.S. standards of medical competency.
4. Completion of International Residency Training:
In states like Tennessee, IMGs are required to have completed at least three years of residency in an accredited international program. This demonstrates that they have already undergone substantial medical training and experience abroad.
5. Supervised Practice Requirement:
In most states, even under the new laws, IMGs must work under supervision for a period (typically two years) before being eligible for full licensure.
The intention behind these qualifications is to ensure that IMGs possess the necessary knowledge and skills to practice medicine safely, even if they didn’t go through a traditional U.S. residency.
Implications: 4 Opportunities and 4 Challenges
In many ways, the new laws for IMGs regarding residency requirements don’t come as a surprise.
According to the American Medical Association, roughly a quarter of the physicians in the US today are IMGs, and that number continues to grow.
Changes in the law are leading to a new reality for patients, doctors trained at home, and those trained abroad. With them come a number of opportunities, but some challenges as well.
Let’s take a look at each.
Opportunities:
1. Faster and Easier Entry into the U.S. Healthcare Workforce:
For IMGs, these alternative licensure pathways represent a significant opportunity to enter the U.S. healthcare system more quickly and with less friction. The traditional residency path is often competitive and limited, with IMGs historically struggling to match into U.S. programs.
The new laws allow many experienced IMGs to bypass this bottleneck and begin practicing in the U.S. sooner and with less stringent requirements.
2. Addressing Physician Shortages:
These changes are particularly relevant in states with severe physician shortages, especially in rural and underserved areas. By making it easier for IMGs to practice, states aim to address healthcare gaps, providing medical services to regions that have long struggled to attract enough doctors to the area.
However, without mandating practice locations for IMGs, we may see the trend continue where physicians migrate to crowded and already saturated big cities, leaving a void for healthcare in underserved and rural areas.
3. Leveraging International Experience:
Many IMGs bring years of medical experience from their home countries, and these laws allow them to use that expertise in the U.S., rather than repeating years of training. This can be especially valuable in areas that need experienced practitioners quickly.
4. U.S. IMG Graduates:
While foreign IMGs receive more years of training through practicing in their home countries, U.S. college graduates who attend Caribbean medical schools do not. Almost half of the IMGs in the U.S. fall into this category, and they have poor match statistics with few alternatives for clinical training or practice abroad. They’re also unlikely candidates for these new licensure pathways.
Though these changes don’t affect them directly, laws that make it easier for IMGs to practice will inevitably help American IMGs by decreasing the competition for residency spots usually taken up by international graduate IMGs.
Challenges:
1. Lack of Standardization:
As for the challenges posed by these changes, one concern is the lack of uniformity in laws across states. Each state sets its own rules for how IMGs can qualify for provisional licenses, which creates variability in oversight and quality assurance.
For instance, Tennessee’s law may differ significantly from Illinois’ or Florida’s in terms of requirements and practice settings. Without standardization, there is a risk of inconsistency in the quality of care provided.
Furthermore, such changes may create additional difficulty and confusion for those applying.
2. Concerns About Supervision and Oversight:
Medical institutions have raised concerns about the level of supervision during the provisional licensure period. With traditional U.S. residency programs, the training is rigorous and standardized across specialties by the Accreditation Council for Graduate Medical Education (ACGME).
By contrast, provisional licensure may not provide the same level of hands-on training, raising questions about how to ensure the same level of competency in patient care. This lack of quality control and standardized supervision may result in care that’s below the standards of the U.S. healthcare system.
3. Economic and Workforce Impacts:
Some critics worry that these laws may create a class of lower-paid, provisional doctors, leading to job competition and possibly reduced wages for physicians in certain areas. Established physicians have expressed concern that hospitals and healthcare systems may rely on provisional license holders as a source of cheaper labor, potentially displacing physicians trained in the U.S.
4. Logistical Challenges:
There are also a lot of unanswered questions, such as will board certification entities allow IMG physicians to sit for board exams without completing an ACGME accredited residency program? If not, then will insurance carriers provide policies for physicians that aren’t board-certified? Will patients care to see such a doctor? And will noncitizen IMGs be able to secure work visas in the U.S. in a timely manner? This is just a sample of the issues that need to be worked out.
Final Thoughts
While these new laws will create significant opportunities for IMGs, the very same laws also raise important questions about quality assurance, workforce dynamics, and what the long-term consequences of them will be for healthcare delivery.
For IMGs, the path forward may be easier, but navigating these new opportunities will require balancing their international experience with the need to meet evolving U.S. standards. One has to wonder, as the healthcare landscape across the country shifts, will other states follow suit?
No one can say for sure, but the idea that IMGs should be able to bypass residency seems to be gaining momentum. It looks to be a brave new world for IMGs, patients, American physicians, and the U.S. healthcare system as a whole.
Looking for more posts for IMGs? Check out these other articles on the Blueprint Med School blog!
