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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 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) 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.

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) , 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 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).

, 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 , 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 .

Idaho and Washington have created temporary pathways to licensure for IMGs. In Idaho, IMGs can 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 , with the option to renew for another 2-year period.

Legislation targeting IMG licensing has been introduced in seven other states: Arizona, Iowa, Massachusetts, Missouri, Nevada, Vermont, and Wisconsin. would shorten its residency requirements to 1 year, and would issue a temporary license only. Proposed legislation in , , and would offer a provisional license for a set time period, after which IMGs can apply for a full license. The 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, (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.

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