Enhancing medical access: alternative licensure pathways for International Medical Graduates (IMGs)

Addressing physician shortages in the U.S.

In response to the growing physician shortages, several U.S. states have introduced alternative licensure pathways. These allow International Medical Graduates (IMGs) to practice medicine without completing a U.S. residency. The primary goal of these programs is to leverage the expertise of experienced foreign-trained physicians, especially in underserved areas. By doing so, the healthcare system can better meet the needs of its communities.

States offering alternative licensure pathways

As of May 2025, the following states have enacted legislation enabling IMGs to obtain medical licenses without U.S. residency:

• Tennessee:

Last year, Tennessee became the first state to ease the transition for experienced doctors from other countries. This state grants provisional licenses to IMGs who've completed a three-year postgraduate training program abroad or have practiced medicine overseas for at least three of the past five years. Applicants must pass USMLE Steps 1 and 2 and obtain ECFMG certification. After two years of supervised practice under a Tennessee-licensed physician, they may receive an unrestricted license. (PubMed Central)

• Florida:

Florida allows IMGs with at least four years of practice abroad and education/training comparable to U.S. standards to obtain provisional licenses. After two years of supervised practice, they can apply for full licensure. (Cato Institute)

• Virginia:

Virginia permits IMGs who have practiced medicine for at least five years abroad and meet educational equivalency standards to receive provisional licenses. They must complete two years of supervised practice before qualifying for an unrestricted license. (Cato Institute)

• Wisconsin:

Wisconsin offers provisional licenses to IMGs who have completed foreign residency programs or equivalent postgraduate training and have at least five years of practice experience. After three years of supervised practice, they may obtain full licensure. (Cato Institute)

• Idaho:

Idaho provides provisional licenses to IMGs with at least three years of practice abroad and training comparable to U.S. standards. After three years of supervised practice in Idaho, they can apply for full licensure. (Cato Institute)

• Iowa:

Starting in 2025, Iowa will grant provisional licenses to IMGs with five years of practice in their home country. After three years of supervised practice, they may transition to full licensure. (Dream US Residency)

• Washington:

Washington offers two-year renewable licenses to IMGs who pass all three USMLE steps and work under supervision. Additionally, applicants must be residents of Washington for at least one year. This initiative aims to alleviate healthcare worker shortages intensified by the COVID-19 pandemic. (International Medical Graduates Clinical Experience License | Washington Medical Commission)

• Arkansas:

Arkansas permits IMGs to obtain licensure without U.S. residency if they are enrolled in a training program through the University of Arkansas for Medical Sciences (UAMS).

• Illinois:

Illinois requires applicants to have ECFMG certification and pass all steps of the USMLE.

• Louisiana:

Louisiana offers initial licensure to IMGs who possess a Doctor of Medicine degree from a board-approved medical school, have ECFMG certification, and pass the USMLE Step 3 exam. Applicants must also have legal authority to reside and work in the U.S.

Recognised equivalent countries

Some states have specified that certain countries' medical education and training are considered "substantially similar" to U.S. standards. These countries include:

• United Kingdom

• Ireland

• Australia

• Switzerland

• Hong Kong

• Singapore

• New Zealand

• South Africa

• Israel

• Canada

  
  

Physicians from these countries may find it easier to qualify for alternative licensure pathways.

Required documentation and evidence

To qualify for these alternative pathways, IMGs generally need to provide:

• Proof of Medical Education: A diploma from a medical school listed in the World Directory of Medical Schools.

• Licensure Verification: Evidence of an active, unrestricted medical license in good standing from their home country.

• Practice Experience: Documentation of a minimum number of years (typically 3–5) of clinical practice abroad. (American Medical Association)

• Postgraduate Training: Certificates or transcripts demonstrating completion of residency or equivalent postgraduate training.

• USMLE Scores: Passing scores for USMLE Steps 1 and 2 (and sometimes Step 3). (BIMS)

• ECFMG Certification: Verification of certification by the Educational Commission for Foreign Medical Graduates.

• English Proficiency: Proof of English language proficiency, often through standardized tests like the OET, necessary for obtaining your ECFMG certification.

  
  

USMLE and clinical experience requirements

While these alternative pathways waive the U.S. residency requirement, they still typically mandate the following:

• USMLE Exams: Passing USMLE Steps 1 and 2 is generally required. Some states may also require Step 3.

• ECFMG Certification: Necessary for verifying the credentials of IMGs.

• U.S. Clinical Experience (USCE): Although not universally required, obtaining USCE can strengthen an applicant's profile and facilitate the transition into the U.S. healthcare system.

  
  

The importance of alternative licensure pathways

The initiatives by different states to enact alternative licensure pathways are crucial. They provide a solution to the doctor shortages, especially after the healthcare challenges posed by the COVID-19 pandemic. By allowing IMGs to practice, we can better leverage their expertise while meeting the healthcare demands of our population.

If you're considering practicing in the U.S., it's essential to stay informed about these changes. For more detailed information, consider visiting the following resources:

• The Match Guy: States Allowing IMGs to Practice Without Residency

• MedSmarter: U.S. States Allowing International Doctors Without Residency

• Cato Institute: More States Move to Let Experienced Foreign Doctors Serve Their Patients

• Federation of State Medical Boards: States with Enacted and Proposed Additional Licensure Pathways (PDF)

• NPR: To Solve for Doctor Shortages, States Ease Licensing for Foreign-Trained Physicians

  
  

These evolving licensure pathways reflect a significant shift in U.S. medical licensing. They offer new opportunities for qualified international physicians to contribute to the American healthcare system.

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