Special Reports > Exclusives

More States Cut Training Requirements for

Some International Medical Graduates
— Alternative pathways to licensing for IMGs spreads
beyond Tennessee
by Kristina Fiore, Director of Enterprise & Investigative Reporting, MedPage
Today March 14, 2024

Nearly a year ago, Tennessee became the first state in the

U.S. to scrap residency requirements for certain international
medical graduates (IMGs), opening up an alternative
pathway to permanent licensure.

Since then, more states have enacted or are close to enacting

similar legislation, and others have shortened residency
requirements for some IMGs.

A MedPage Today analysis found a total of 15 states have

passed or are considering legislation around establishing
alternative pathways to licensure for IMGs.
"It's a really interesting time. There's so much activity," Hao
Yu, PhD, a health policy expert at Harvard Medical School in
Boston and author of a New England Journal of Medicine
perspective on the Tennessee law, told MedPage Today.

Supporters say cutting residency requirements aids a group

that has historically faced barriers to obtaining a U.S. medical
license, such as being the least likely to match into a
residency program. At the same time, it can help solve
workforce issues, such as filling an unmet need for clinicians
in rural or underserved areas.

But physicians have raised questions and concerns. Should

these candidates be held to some type of national standard
after their supervision, especially if state laws continue to
vary widely? Doctors have also raised alarms that hospitals
potentially benefit from a less expensive source of labor --
and wonder if it will cost them their jobs.

Some IMGs Can Now Bypass Residency

A total of four states have or are very close to having

eliminated residency requirements for certain IMGs.

In April 2023, Tennessee Gov. Bill Lee (R) signed into law a bill
that enables IMGs to skip residency and instead get a 2-year
provisional license to work at a healthcare facility that has
an accredited residency program. After 2 years, they can
apply for a full license.

However, applicants must already be "legally entitled to live

or work in" the U.S., and must obtain their own visa or
permanent resident card.

They also must be certified by the Educational Commission

for Foreign Medical Graduates (ECFMG), now a division of
Intealth; pass the U.S. Medical Licensing Exam (USMLE) Step
1 and 2 CK; and have completed at least a 3-year residency at
an accredited international program.

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The Tennessee law goes into effect on July 1 of this year.

"IMGs are really excited by this new law," Yu told MedPage

Today. "They want to take advantage of it."

In September 2023, Illinois Gov. J.B. Pritzker (D) enacted

similar legislation, wherein IMGs can work for 2 years with a
provisional license under the supervision of a licensed
physician, and then can apply for a full license.

Like Tennessee, IMGs would have to be legally able to work

in the U.S., but unlike Tennessee, the law mandates that they
must work in medically underserved areas. It takes effect on
Jan. 1, 2025.

"We really see this as having the potential to support

thousands of IMGs in Illinois, to move into skill-aligned work
and enter into the healthcare industry," said Avigail Ziv, MPH,
vice president of programs at Upwardly Global, an advocacy
organization that championed the Illinois legislation. "And
not only that, but to address the real shortages that exist in
the healthcare industry and workforce."

Two additional states are close to enacting legislation that

cuts residency requirements and establishes an alternative,
permanent pathway to licensure for some IMGs: Florida and
Virginia.

In both cases, relevant bills have passed the state House and
Senate, and await each governor's signature.
The Florida provision will allow IMGs to skip residency
requirements if they've completed similar post-graduate
training that meets state and national standards. It's part of
a larger healthcare workforce bill awaiting the signature of
Gov. Ron DeSantis (R).

In Virginia, IMGs will be able to obtain a 2-year provisional

license to work at an academic center with an accredited
residency program. After that, they can apply for a full,
unrestricted license to practice medicine.

Other Pathways

Four states have taken other actions around residency

requirements for IMGs, including cutting down residency
length and establishing a temporary pathway for licensure.

Alabama recently passed the Physician Workforce Act, with a

provision that allows IMGs to apply for a license a year
earlier during their training -- essentially cutting residency
requirements from 3 to 2 years.

Colorado also recently shortened residency requirements for

IMGs from 3 years down to 1 year.

Idaho and Washington have created temporary pathways to

licensure for IMGs. In Idaho, IMGs can obtain a temporary
license if they are "forcibly displaced" and if they've applied
to an accredited residency program in the state. They'll also
have to work in an underserved area for at least 3 years after
they've completed residency.

In Washington, IMGs who have been a state resident for at

least a year can obtain a temporary 2-year license, with the
option to renew for another 2-year period.

Legislation targeting IMG licensing has been introduced in six

other states: Arizona, Iowa, Massachusetts, Missouri, Nevada,
and Vermont. Arizona would shorten its residency
requirements to 1 year, and Nevada would issue a temporary
license only. Proposed legislation in Iowa, Massachusetts,
Missouri, and Wisconsin would offer a provisional license for
a set time period, after which IMGs can apply for a full
license. The Vermont bill seeks to establish a work group to
consider Tennessee's legislation.

But it remains to be seen whether any of these bills will

advance.

Striking a Balance

Even though a quarter of all U.S. physicians are IMGs,

according to the American Medical Association (AMA), it's not
easy for them to get their U.S. medical licenses.

Having to go through a U.S. residency program, on top of

training they've already received in their licensing countries,
is time-consuming and difficult, on top of being costly, Yu
said.

That's if they can even get a position, he added, noting that

IMGs are the least likely of all medical graduates to match
into a residency program.

At the same time, the U.S. needs healthcare workers,

according to Ziv of Upwardly Global, which estimates there
are 165,000 unemployed or underemployed immigrants with
international healthcare degrees already in the U.S.

Their services can be especially helpful as the U.S. population

ages, and as demand rises for doctors in rural and other
medically underserved areas.

"They come with knowledge and years of experience," she

said. "How can we leverage that talent to support our
healthcare industry?"

She gave the example of a woman who recently immigrated

to the U.S. who was a surgeon in Afghanistan: "She has years
of experience and depth of expertise, but she's not able to"
work as a surgeon in the U.S. at this time.
But medical societies are hesitant to comment on the
legislation popping up across the country, and some doctors
have shared concerns about IMGs skipping residency
training.

Yarnell Beatty, general counsel at the Tennessee Medical

Association (TMA), said some of the group's members
reached out after the legislation was passed last year.

"Some expressed concerns about it, in terms of the ability to

demonstrate quality," Beatty told MedPage Today.

Yu said there could be a role for a national organization to

develop a standard of quality that would have to be met
following completion of provisional licenses.

"There's heterogeneity across medical training, and residency

standardizes things," Yu said. "How can we ensure quality
during the 2-year provisional licensing period?"

Eric Holmboe, MD, CEO of Intealth, noted that the Tennessee

legislation specifically requires ECFMG certification as part of
its credentialing process, and noted that the nature of
oversight "varies a bit by state, which is honestly a bit of a
challenge."

He added that Intealth, the Federation of State Medical

Boards (FSMB), and the Accreditation Council for Graduate
Medical Education (ACGME) have formed a work group that's
meeting in April to "talk about how we can create a more
standardized process. One that states could use as part of a
pilot program that would have an evaluation to see if this
alternative pathway is producing the outcomes that these
states hope for."

Humayun Chaudhry, DO, president and CEO of FSMB, told

MedPage Today that some states have asked about his
organization's position on the legislative changes, which in
part prompted the upcoming meeting in April.
"The primary mission of state medical boards is to protect
the public, and we want to make sure that access to care is
being addressed though this particular approach, and that
patients are protected and not harmed," Chaudhry said.
"We're going to be starting some conversations about criteria
or competencies that a state board should expect before
they issue a temporary license."

Beatty also said that some TMA members raised concerns

about potentially losing their jobs, as the academic medical
centers in Tennessee where provisional licensees are required
to practice find a source of less expensive labor.

"They were concerned that these graduates would come in

and accept cheaper salaries, and established physicians
might be pushed out," he said.

Bryan Carmody, MD, MPH, a pediatric nephrologist at Eastern

Virginia Medical School in Norfolk, who has long studied
data on residency and the Match process, said that the influx
of labor would be good for academic medical centers in
Tennessee.

"They can hire experienced physicians at bargain rates,"

Carmody said in a video on the topic.

In an interview, Carmody noted to MedPage Today that

Tennessee and Florida are "probably the two biggest HCA
[Healthcare] states. You have to think that ultimately, one
beneficiary of this are health systems who get access to
more abundant and cheaper physician labor."

Beatty said "hundreds of potential applicants" have

contacted the Tennessee Board of Medical Examiners
(TBME), interested in applying. A spokesperson for the TBME
said applications "are not being accepted yet" but told
MedPage Today that the legislation will be discussed at an
upcoming board meeting in May.
Beatty added that TMA originally deferred to TBME on
reviewing the bill, and TMA remained neutral on the bill. He
noted that placeholder legislation has been introduced with
the goal of "tamping back" the law.

The AMA told MedPage Today that it "defers to local state

medical associations to take the lead on state-level
legislation as the voice and advocate of local physicians in
the state legislature," noting that it has at the same time
"adopted numerous policies that demonstrate strong
support for [IMGs] during and after training."

These include allowing state medical boards to have an

alternate set of criteria for granting medical licenses outside
of going through a U.S. residency program; encouraging
boards to evaluate the progress of programs aimed at
reducing barriers to licensure for IMGs; and encouraging
relevant stakeholders to "study the personal and financial
consequences" of not matching for IMGs.

Kristina Fiore leads MedPage’s enterprise & investigative reporting team. She’s
been a medical journalist for more than a decade and her work has been
recognized by Barlett & Steele, AHCJ, SABEW, and others. Send story tips to
k.fiore@medpagetoday.com. Follow

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