This potentially controversial tactic could alleviate physician shortages

By Alpana Mohta, MD, DNB, FEADV, FIADVL, IFAAD | Fact-checked by Barbara Bekiesz
Published May 6, 2024

Key Takeaways

  • A new law in Tennessee enables easier licensure for international medical graduates (IMGs), mirroring programs in Canada and the UK, aiming to address physician shortages in the state.

  • Similar measures in other states could increase residency slots for US medical graduates by allowing IMGs to skip US residency requirements, potentially easing competition for training positions.

  • The focus on urban training of license-seeking IMGs in these states, however, may limit efforts to address the shortage of physicians in rural or underserved areas.

International medical graduates (IMGs) who earned their medical degrees outside the US and Canada compose a quarter of the physician workforce in the US. Although they contribute to addressing the nationwide scarcity of physicians, especially in underserved regions, IMGs often find it more difficult to obtain licensure than their counterparts educated in the US or Canada.

A recent legislative development in Tennessee aims to alleviate these difficulties and broaden IMGs' prospects for medical practice.

The shared struggles of IMGs

There are many other challenges IMGs must face, including cultural differences, difficulty in adapting to the healthcare system, communication barriers, emotional distress, racial discrimination, and financial constraints.[]

Authors writing in The New England Journal of Medicine offer a perspective on this unique initiative.[] To practice in the US, IMGs must complete a US residency program—even if they have residency experience or have practiced medicine elsewhere (except from Canada). In their perspective piece, the authors state, “While the mandated US-based residency training intends to standardize training quality, it presumes that IMGs received substandard training overseas and causes duplicative clinical training with unclear benefit to their skills and competencies.” 

Moreover, hospitals often don't cover H-1B visa costs. Many IMGs opt for the J-1 medical trainee visa, with some utilizing the Conrad 30 waiver, which permits them to switch to an H-1B visa by committing to work in health professional shortage areas (HPSAs). 

These hurdles may limit IMGs' skill utilization and cause some to drop out of training.

The Tennessee Bill

Tennessee passed Senate Bill 1451 in April 2023 to reduce the state's physician shortage by making it easier for IMGs to practice. Effective July 2024, this law will permit IMGs licensed abroad to obtain provisional licensure in the US without completing a US residency—akin to programs in Canada and the UK.

Requirements include passing the US Medical Licensing Examination (USMLE) Steps 1 and 2, receiving ECFMG certification, and completing a 3-year accredited international residency or 3 years of practice within the last 5 years. 

The legislature reduces the licensing pathway from over 3 years of residency to a 2-year provisional period and replaces trainee licenses with provisional ones. Additionally, eligible IMGs wouldn’t be required to participate in the National Resident Matching Program (NRMP) or fulfill ACGME core competencies. Moreover, it provides IMGs with greater freedom to choose their preferred area of specialization and practice location.

Different approaches

Many states are on the brink of adopting similar laws that will alter the licensure process for IMGs.

Consider the following:

  • In Florida, a component of broader healthcare workforce legislation proposes exempting IMGs from residency mandates if their postgraduate training aligns with US and Florida benchmarks.[]

  • Virginia intends to introduce a system whereby IMGs can receive a provisional 2-year license to practice at an academic institution with an accredited residency program—followed by the opportunity to seek a full, unrestricted medical license.[]

  • Alabama’s Physician Workforce Act includes a clause permitting IMGs to apply for licensure a year earlier in their training, reducing the residency duration to 2 years.[]

  • Colorado has gone a step further by diminishing the residency requirement for IMGs from 3 years to just 1.[]

Impact on US medical graduates

In 2023, US and non-US IMGs collectively represented about 40.5% of all residency applicants during the NRMP.[] Their significant presence contributes to the heightened competition for the limited number of residency positions, playing a role in why somewhat under 10% of US medical graduates do not match each year.[]

The Tennessee law and similar ones in other states could indirectly create more residency opportunities for US graduates by allowing international doctors with equivalent training to bypass US residency, thereby freeing up positions.

Impact on IMGs

Even though IMGs actively participate in the National Resident Matching Program (NRMP), their match rate is only about 60%.

Currently, they are obligated to work for 3 years in HPSAs.[] The new legislation, however, might lift this requirement, streamlining IMGs' entry into the US healthcare system and offering them greater choice in their workplace, potentially including urban areas. If other states replicate this approach, IMGs may increasingly opt for provisional licenses instead of the J-1 waiver path.

While beneficial for students, the strategy may not effectively tackle the physician shortage in rural and underserved areas. Tennessee's law mandating IMGs to work in hospitals with ACGME-accredited residency programs during their 2-year supervision, which predominantly exist in urban areas, limits rural exposure for IMGs.

What this means for you

Initiatives across multiple US states could ease the integration of IMGs into the US healthcare system. As a result, these laws will also increase residency slots for US medical graduates by allowing international physicians to skip US residency requirements. However, requiring IMGs to work in ACGME-accredited residency hospitals for 2 years, primarily in urban areas, may not effectively tackle physician shortages in rural and underserved areas.

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