The Accreditation Council for Graduate Medical Education (ACGME) aims to earn the privilege of being called upon by policymakers as a trusted authority on matters related to physician education and the physician workforce. An essential aspect of earning that trust is understanding the context in which policy development occurs and the specific drivers of policy approaches.
Recently, states have become increasingly active in devising solutions to pressing health care issues such as workforce shortages and deficits in health care access. One area that is subject to increasing legislative focus is the traditional requirement that physicians complete some or all of an American Osteopathic Association- or ACGME-accredited residency to be eligible for state licensure. While many states have exceptions to this requirement, these exceptions are typically limited to individual exceptional physicians or academic appointments.
Laws passed during 2023-2024 state legislative sessions have fundamentally changed the licensure pathways for physicians who trained and/or practiced outside of the United States, bypassing traditional requirements for US postgraduate training and other requirements designed to ensure physicians have acquired the necessary knowledge, skills, abilities, and attitudes to provide safe and competent care. Several states have authorized the development of alternative licensure pathways, whereby certain physicians who have not trained in a US postgraduate program but have trained and/or practiced abroad are eligible for full and unrestricted licensure following a period of supervised practice under a provisional license.
While these laws share some common features, there are also distinctions that could lead to varying outcomes across states and create confusion among physicians, regulators, and patients. In some cases, it is also unclear how medical boards and regulators will operationalize the proposed pathways.
The following is a brief overview of these recently proposed and enacted laws, as well as other state approaches to providing international physicians a pathway to practice.
Incorporating International Physicians Into the US Health Care System
The concept of utilizing internationally trained physicians to address the health care workforce shortage is not a novel one. Many states have developed pathways programs to facilitate the integration of international medical graduates (IMGs) into the US medical education system. For example, the Licensed Physicians from Mexico Pilot Program1 authorizes the Medical Board of California to issue a 3-year license to practice medicine in California to up to 30 licensed physicians from Mexico specializing in family practice, internal medicine, pediatrics, obstetrics, and gynecology. To be eligible to participate in this program, the individual must be licensed, certified or recertified, and in good standing in their medical specialty in Mexico. They must also complete other requirements before leaving Mexico, including completing a board-approved orientation program that covers medical protocol, community clinic history and operations, medical administration, hospital operations and protocol, medical ethics, and the California medical delivery system, among other topics.
Other legislation has served as a pathway for preparing internationally trained physicians for US residency programs. A 2015 Minnesota law created the IMG Primary Care Residency Grant Program,2 which provides resources and support, including clinical readiness assessment and a clinical readiness program, for IMGs interested in entering the Minnesota health workforce. The state also provides grants to support primary care residency positions for Minnesota IMGs who agree to practice postresidency in rural or underserved areas of the state. Similarly, a 2022 Colorado law3 authorized “clinical readiness” programs to assist IMGs in building the clinical skills necessary to participate in a Colorado primary care residency program.4
Meanwhile, some states have studied the best approaches for utilizing the international physician workforce. In 2019, Massachusetts passed legislation establishing the Special Commission on Foreign Trained Medical Professionals.5 The Commission was charged with conducting a study and making recommendations regarding the licensing of internationally trained health professionals with the goal of expanding and improving medical services in rural and underserved areas. In 2023, Maine formed a commission to explore options for helping enable foreign-trained physicians to best use their skills and talents, increase health care workforce cultural competency, and address potential workforce shortages.6
Alternate Licensing Pathways
While these state pathways lead to IMG participation in a US-based residency program, the approach of state legislatures from 2023 to 2024 has been to dispense with the requirement that IMGs complete some or all of a US residency program to be eligible for licensure. During this period, several states have enacted laws that allow physicians who have completed their education and training outside of the United States or Canada and meet certain criteria to be licensed without completing any additional graduate medical education training in the United States (including Florida, Iowa, Idaho, Illinois, Tennessee, Virginia, Louisiana, and Wisconsin). In most of these states, regulation to implement the new legislative framework remains pending. Several additional states (Arizona, Kentucky, Massachusetts, Maine, Michigan, and Minnesota) proposed legislation during the 2023-2024 legislative session, which either remains pending or did not pass.
Under these evolving frameworks, physicians who trained and practiced in another country may be granted provisional licensure for a specified period, often under the supervision of a physician or the institution from which they have an offer of employment after which the physician is eligible for a full and unrestricted license. Common requirements also include completion of medical school, international postgraduate medical education and/or practice, work authorization, an offer of employment, licensure in another country, and English fluency.
Most of the physicians eligible for these pathways are IMGs, encompassing foreign nationals and US citizens. States vary in their requirements for Educational Commission for Foreign Medical Graduates Certification, completion of the United States Medical Licensing Examination, the number of years of practice required, and whether any gap in practice is allowed before applying for a provisional license. States also differ in their approach to the training required, with some states requiring postgraduate medical education (PGME) substantially similar to US training, some states accept PGME from a specific list of countries, while still others accept a minimum number of hours of practice in lieu of PGME.
While the requirement of an offer of employment is almost universal within the legislation, the specifics vary by state. For example, in some states, the employment offer can come from individual practitioners, while in other states, only certain types of entities, such as Federally Qualified Health Centers, would qualify.
Advisory Commission on Alternate Licensing Models
State medical boards and regulators have the responsibility to operationalize these new licensure pathways. Recognizing the need for expertise and guidance to state medical boards as they embark on the implementation and operationalization of these laws, the ACGME, the Federation of State Medical Boards, and Intealth established an Advisory Commission on Alternate Licensing Models.7 The goal of the Commission, which also includes national organizations representing specialty certification, state licensing boards, and medical education, is to develop meaningful recommendations for licensure requirements and pathways for internationally trained and practicing physicians. The Commission has begun its work and hosted a symposium in Washington, DC, in June 2024. It is expected to issue recommendations and guidance, and identify resources for states, in the coming months.
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Editor’s Note
The ACGME News and Views section includes data reports, initiatives, and perspectives from the ACGME and its review committees. The decision to publish the article is made by the ACGME.
