Can New State Licensing Pathways for Foreign Medical Graduates Reshape Physician Staffing and Recruitment Landscape?

• States are increasingly enacting and considering laws authorizing alternative licensing pathways for internationally-trained physicians to practice medicine in the United States. 
• These laws, which vary from state to state, have significant implications for organizations that rely on international medical graduates (IMGs) to fill clinical roles as well as organizations that assist with physician staffing.
• These state-based reforms represent an innovative attempt to address a growing workforce crisis but also introduce legal, regulatory and clinical complexities that health care organizations must carefully navigate.

In response to growing physician workforce shortages, an increasing number of states have enacted or are considering new laws to create alternative licensure pathways for internationally trained physicians that bypass the traditional U.S.-based graduate medical education (GME) residency requirements. Ultimately, these reforms are intended to address physician shortages and expand access to care, as the U.S. is projected to see a 34% increase in Americans over the age of 65 by 2036, coupled with an aging physician population.

Laws authorizing alternative licensing pathways have been enacted in at least 18 states and are under consideration in more than a half dozen others. These laws have significant implications for organizations that look to IMGs, but there are still many unknowns to know if these laws will make a difference in confronting healthcare workforce shortages.

In 2021, Washington state became one of the first states to enact this pathway but have only granted around 40 licenses so far. Employers may be mindful of the extra work required of supervising physicians should they leverage an alternative licensing pathway. Minnesota, for example, requires the internationally-trained physician shadow their supervising physician initially during the two-year provisional licensure period to determine the level of supervision that is required.

The supervisory burden, credentialling complexity and qualifications of candidates compared to those in U.S. residency programs highlight ongoing uncertainties regarding this pathway’s impact. Healthcare organizations should continue to monitor these developments in states where they operate.

Background

Historically, most IMGs seeking to practice in the U.S. have done so via the Conrad 30 J-1 visa waiver program, which requires completing a U.S. residency and serving in an underserved area for at least three years. This program is enormously successful in creating incentives for IMGs to practice in primary care in medically underserved areas that struggle to recruit American physicians. While each state is only allotted 30 waivers under the Conrad 30 program, it ensures that highly trained and skilled physicians are going to areas that have a demonstrated need.

Because some states do not require internationally trained physicians to practice in underserved areas, these new pathways may be less effective in addressing acute workforce shortages than the Conrad 30 program.

Key Features of New State Licensure Laws

Alternative licensure pathways vary significantly by state, with each imposing its own set of requirements. However, state approaches often include the following elements:

• Eligibility for Limited Licensure: Physicians must be certified by the Educational Commission for Foreign Medical Graduates (ECFMG) and have completed medical education and training in their home country comparable to U.S. standards.
• Supervised Practice Period: Initial licensure is limited to supervised practice—typically two to three years—at a qualifying facility, often in an underserved or rural area.
• Pathway to Full Licensure: After demonstrating competence under supervision and passing relevant U.S. licensing exams (e.g., USMLE Steps 1–3), physicians may be eligible for full licensure without repeating U.S. graduate medical education.

Implications for Health Care Providers and Recruiters

Alternative licensure pathways for internationally trained physicians theoretically broaden the pool of eligible candidates by allowing certain physicians to obtain provisional or full licenses without completing a U.S. residency. However, the actual number of qualified physicians who can take advantage of these opportunities may be limited. Eligibility requirements—such as ECFMG certification, successful completion of all required USMLE steps and substantial prior clinical experience—remain stringent. For example, some states require internationally trained physicians to have practiced as fully licensed physicians in good standing for at least five years after postgraduate training, with at least one year of continuous practice immediately preceding the application. As a result, the immediate impact of these reforms on the physician workforce may be constrained.

Possible Opportunities:

• Expanded Talent Pool: Providers in rural and underserved areas may now have access to a broader pool of qualified, foreign-trained physicians.
• Streamlined Hiring: Alternative pathways may reduce barriers for onboarding experienced clinicians.
• Addressing Access Gaps: These laws could help fill long-standing gaps in primary care and other in-demand specialties.
• Recruitment and Outreach: Given the limited pool of eligible physicians, providers and recruiters may wish to develop targeted outreach and recruitment strategies, both domestically and internationally, to raise awareness of these new pathways and attract qualified internationally trained physicians.

• Jurisdictional Variability: State-specific requirements add another layer of complexity for national organizations and may significantly limit the potential pool of eligible candidates.
• Supervisory Burden: Many pathways require these physicians to practice under supervision for a temporary period. The success of these programs depends on the willingness of existing qualified physicians to serve as supervisors, which may require additional incentives or support from health systems. Without sufficient supervisory capacity, implementation could stall.
• Licensure and Credentialing Complexity: Licensure processes vary by state and may not align with hospital credentialing standards or malpractice insurer requirements. Some insurers may be reluctant to cover physicians licensed via nontraditional pathways, while misalignment between state licensure and institutional requirements could impede hiring and practice.
• Quality and Oversight Concerns: Without the uniform structure of U.S. GME programs, some experts question whether these pathways ensure consistent clinical competence.
• Specialty Certification Barriers: Many specialty boards may not recognize physicians who have not completed ACGME-accredited residencies. Therefore, these pathways are most likely to benefit primary care providers, without addressing specialist shortages.
• Immigration Concerns: State licensure does not resolve federal immigration challenges. Even highly qualified internationally trained physicians may be unable to practice due to visa restrictions or the absence of a clear employment authorization pathway. This remains a major limiting factor and the practical effect of state-level reforms may be muted unless sufficient federal immigration pathways are available.

1. Monitor Legislation in Key States: Providers should assess whether any states where they operate have adopted or are considering such pathways.
2. Review Credentialing and Hiring Policies: Update protocols to account for new licensure routes and ensure compliance with payer, accreditation and insurer standards.
3. Assess Risk and Insurance Implications: Work with counsel and insurers to evaluate whether new hires under these laws meet your liability coverage and risk tolerance.
4. Coordinate with Recruitment Teams: Ensure internal recruitment teams understand the evolving legal landscape and the qualifications required under new state pathways.
5. Advocate for Standards: Industry stakeholders may want to engage with state medical boards and legislatures to help shape policies that maintain high standards for quality and safety.

While these state-based reforms represent an innovative attempt to address a growing workforce crisis, they also introduce legal, regulatory and clinical complexities that health care organizations must carefully navigate. Foley Hoag’s Healthcare Department is actively tracking these developments, including federal immigration laws, regulations and legislative proposals that impact pathways for international medical graduates and other providers trained abroad.