An International Medical Graduate (IMG) is a physician who received a medical degree from a medical school located outside the United States or Canada. An IMG can be either a U.S. citizens or a non-U.S. citizen. Currently, IMGs represent more than 25% of the U.S. physician working population.
Recent data from the Association of American Medical Colleges (AAMC) confirms that the U.S. continues to face a projected shortage of up to 86,000 physicians by 2036. IMGs have and will continue to play a critical role in the U.S.' ability to provide adequate medical care for all Americans, particularly considering these ongoing shortages.
However, the ability of IMGs to practice medicine in the U.S. relies on a complicated system of state and federal healthcare regulations, licensing requirements and U.S. immigration laws.
As a result, in the absence of meaningful congressional reform, states have attempted to fill these healthcare shortage gaps by making the process easier for IMGs to practice – while nevertheless ensuring that all physicians practicing medicine in the U.S. are qualified and safe.
Education and training barriers in U.S. healthcare
Medical training varies from country to country, and while the World Federation for Medical Education & WHO have pushed for global harmonization of medical training programs to unify standards, there is still work to be done.
While the U.S. and Canada have a shared accreditation process for certain medical schools, the lack of global efforts to standardize medical education and training means that the U.S. has implemented a rigorous system to ensure that IMGs possess a minimum standard of training through a system of training, testing and licensing requirements.
Any IMG seeking to practice in the U.S. must ordinarily complete a U.S. residency and fellowship program. Despite persistent shortages as noted above, achieving this training is complicated by the fact that Congress has effectively capped spots in these training programs since 1996. Despite this, matching to U.S. residency and fellowship programs remains competitive and highly selective.
In 2024, ECFMG announced that 9,045 IMGs obtained first-year residency positions in accredited U.S. GME programs. This was an increase of 657 IMGs (7.8%) from 2023. This comprises more than a quarter of all matched applicants (25.1%). But training is just one aspect of the journey an IMG takes to practice in the U.S.
Licensing barriers in U.S. healthcare
Each state is responsible for implementing licensing requirements for professionals, including physicians. State licensing requirements exist as we have a public policy interest in ensuring that the people caring for our health are competent and vetted.
However, the formidable licensing requirements for IMGs have a disproportionately negative impact on an IMGs ability to practice medicine in the U.S. While certain states – and USCIS – extended modest relaxations during the pandemic to ensure access to care nationwide, most did not remain long-term. Given the formidable barrier to entry for many IMGs, many states have been assessing whether there is some way to help streamline, or standardize, licensing to reduce barriers to entry.
There are two major requirements for IMGs to be licensed to practice in the U.S.
First, all IMGs, regardless of their U.S. citizenship status, must complete a U.S.-based residency even if they have previously completed a residency and/or practiced medicine in another country. While this mandated-based residency training intends to standardize training quality, it ignores the training the IMG received abroad and duplicates not only the training but extends time and cost to IMGs who are already clinically trained.
Second, after completing a U.S. residency or fellowship program, noncitizen IMGs must obtain proper immigration authorization to work in the U.S., which can be complicated and lengthy to achieve – all of which they must do while undergoing their rigorous U.S. training programs.
Because of these barriers, and the lack of congressional relief, many states are passing legislation that will help ease the transition of IMGs into clinical practice in the U.S., specifically to address the pervasive shortage of physicians in rural and urban underserved communities.
Opening pathways to practice for IMGs
Immigration law is federal, but because licensing requirements are left to the states, they are starting to implement creative solutions to the healthcare crisis in the U.S. by easing licensing requirements for IMGs.
Here is a brief review of state-driven solutions to increase the number of practicing IMGs:
- Minnesota IMG Program (2015) - Minnesota was the first state in the nation to implement a comprehensive program to integrate IMGs into the physician workforce, recognizing their potential to address pressing issues of healthcare disparities and workforce shortages. Through this innovative program, Minnesota focused on legal, internationally trained doctors who are underemployed or unemployed in rural and urban underserved communities. Minnesota's IMG program consists of three parts: 1) Providing career guidance and support services, which help IMGs ready themselves to apply for residency or to seek alternative primary care pathways that will allow them to make use of their medical background in helping Minnesotans; 2) Clinical preparation via the BRIIDGE program, which is a nine-month residency preparatory program at the University of Minnesota that helps IMGs develop the clinical skills necessary to become successful residents in the United States medical system; and, 3) Creating 2-3 state-funded primary care residency slots for IMGs. Since its creation in 2015, this program has enabled 15 IMGs to enter residency training programs, eight of which are now providing critical care in rural and urban underserved communities.
- UCLA IMG Program (2018) –UCLA's IMG Program seeks to help ease the U.S. physician shortage by helping IMGs who have already graduated from a medical school outside of the U.S, Puerto Rico or Canada pass their U.S. licensing exams and obtain U.S. residency training in Family Medicine. This program is a pre-residency program that helps IMGs obtain ECFMG certification, pass the USMLEs and successfully apply for the National Resident Matching Program.
These programs can serve as templates for other states seeking to expand access to care by retaining IMGs and their expertise.
Additionally, at least 15 states have passed legislation or are looking at legislation that relaxes licensing requirements to help ease the transition of U.S.-trained physicians into practice.
Eight states have passed or are close to passing legislation that removes or reduces residency training, including Tennessee, Illinois, Florida, Virginia, Alabama, Colorado, Idaho and Washington State.
States' continued endeavors to create new laws to ease licensing requirements demonstrate the vital role IMGs play in ensuring access to healthcare in the U.S., particularly in rural and urban underserved communities.
Even with these innovative state programs, IMGs still face federal immigration restrictions. In the absence of Congress passing meaningful, bipartisan reform, including the Conrad Reauthorization Bill and the Healthcare Workforce Resilience Act, we will continue to see states step into the U.S. immigration void to pursue economic immigration programs that benefit all Americans.
Originally published April 3, 2024.
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