Rethinking the Standards for State Licensure of Physicians

• Graduate Medical Education
• Health Policy
• Health Workforce
• International Medical Graduates
• Medical Licensure
• Medical Residency
• Physicians

The National Center for Health Workforce Analysis of the Health Resources and Services Administration (HRSA) projects that the US will face a shortage of 139,940 physicians by 2036.¹ In 2023, 28,811 US medical graduates received an MD or DO degree.² While this is the largest number of medical graduates in history,² it is hardly a match for the number of physicians who plan to retire. Over 100,000 physicians left practice in 2021,³ and surveys from 2021 projected that 1 in 5 physicians were planning to retire by the end of 2023.⁴ While these figures may be due in part to the COVID-19 pandemic, it nonetheless seems that the US medical education system may not be able to sustain the current workforce or meet increasing demands over the next decade.

One option to address this shortfall is to increase the number of physicians practicing medicine in the US who graduated from medical school outside the US or Canada, heretofore referred to as international medical graduates (IMGs). While data directly addressing the quality of care provided by IMGs may be limited, there is no doubt that they are making a substantial contribution to the delivery of health care in the US.^5,6 The number of IMGs holding medical licenses was 188,598 in 2010, representing 22.2% of the licensed physicians in the US.⁷ By 2022, the number of licensed IMGs had increased to 239,642; however, this represented only a slight increase to 22.9% in the proportion of licensed physicians who were IMGs.⁷ While recent years have seen a modest increase in the number of PGY-1 positions, the rate of increase has been slow, averaging just over 1,000 new positions per year for the past 5 years.⁸ When viewed through the lens of IMG match rates (most recently, 44% for IMGs who are US citizens and 38% for IMGs who are not US citizens),⁸ it becomes clear that the number of graduate medical education (GME) positions will limit the entry of new IMGs into the US Health care system.

Regulations governing the medical licensing of IMGs vary state by state. As per the Federation of State Medical Boards, 43 state medical boards in the US and its territories do not approve physician licensure applicants whose GME was completed outside of the US or Canada.⁹ Twenty-four boards grant some credit for GME outside the US or Canada.⁹ However, this is a regulatory landscape in a state of flux.

In April of 2023, Tennessee Governor William B. Lee signed an amendment to the law governing the process by which IMGs would become licensed to practice medicine in the state.¹⁰ Under SB1451, a licensed physician from outside the US or Canada who has completed residency training or practiced for at least 3 of the last 5 years will be allowed to forego residency training in the US if they fulfill several requirements. Among these are a demonstration of competency and an offer of employment from a health care clinician that “has a postgraduate training program accredited by the Accreditation Council for Graduate Medical Education” (ACGME).¹⁰ The amended law, which went into effect on July 1, 2024, further allows transition to a full and unrestricted medical license after 2 years of employment.¹⁰

The amendment to the extant law governing physician licensure is surprising in its brevity. A “health care clinician” is broadly defined as “an individual, entity, corporation, person, or organization, whether for profit or nonprofit, that furnishes, bills, or is paid for a health care procedure or service delivery in the normal course of business, and includes, but is not limited to, a health system, hospital, hospital-based facility, freestanding emergency facility, and urgent care clinic.”¹⁰ The law does not provide details regarding the mechanism or processes for demonstrating competency, nor does it stipulate the requirements for transition to a full medical license.

Passage of the Tennessee law was followed soon after by passage of the Physician Workforce Act in Alabama, which went into effect on August 1, 2023.¹¹ This law reduces the requirement for domestic graduate education for IMGs from 3 to 2 years without specifying which postgraduate years must be completed. Both laws reflect concern on the part of 2 states suffering under a shortage of physicians. In 2024, the US averaged 328 physicians per 100,000 population.^12,13 Alabama and Tennessee were below the median at 256 and 283 physicians per 100,000 population, respectively (Figure 1).^12,13 However, these 2 states are no more disadvantaged with regard to this metric than many others. In fact, laws like these are proliferating. At the time of this writing, at least 13 additional states (Arizona, Colorado, Florida, Idaho, Illinois, Iowa, Massachusetts, Missouri, Nevada, Vermont, Virginia, Washington, and Wisconsin) have enacted or are considering legislation to reduce GME requirements for IMGs to 1 year, or eliminate GME requirements altogether through the institution of provisional medical licensure programs.¹⁴ The states considering or enacting these programs vary widely with regard to the size of their physician workforce (Figure 1). In fact, Massachusetts is the state with the greatest number of physicians per 100,000 population.^12,13 A comparison of states that have reduced or eliminated graduate education requirements for IMGs, or may do so, versus those that have not yet undertaken such steps demonstrates no significant difference in the number of physicians per 100,000 population (unpaired t test, P = .45). One is left to conclude that the magnitude of the shortfall of physicians in any particular state is not predictive of the likelihood that a state will take steps to grow its physician workforce through a provisional licensure program or other approaches to lower barriers to licensing for IMGs.

Of particular note is an aspect of the Alabama law that has not yet been replicated in any other state. In addition to expediting entry of new IMGs into the state’s workforce, the law also focuses on recent graduates of accredited US and Canadian medical and osteopathic schools.¹¹ These new graduates will be allowed to enter a program so that they might practice as “a bridge year graduate physician” under the supervision of an Alabama-licensed physician. This opportunity for limited, supervised practice would be granted to graduates who have applied for, but not accepted into, a postgraduate or residency training program. Stated differently, this opportunity would be afforded to those medical students, fewer than 10% of new US and Canadian medical school graduates,⁸ who went unmatched in the National Residency Matching Program. Following the bridge year and, if approved, a second year, the graduate physician may be provided a recommendation for residency to be used on reapplication. To be clear, this is not a path to licensure. Rather, it seems to be a means to encourage unmatched medical school graduates to pursue careers as practitioners in Alabama.

The reasons that medical students go unmatched are varied. They include poor or failing performance on licensing examinations, poor interviewing skills and qualifications that are poorly matched to competitive residency choices.¹⁵ Given the cost of medical education and the debt incurred by many students,¹⁶ the bridge year program clearly offers benefits for its participants. Those graduates may undertake activities during a gap year before reapplying that do not benefit their career development in a direct way. However, it should also be noted that the program, presuming its ultimate goal of recruiting newly minted physicians to the workforce in Alabama, will require care and diligence in assuring that this population of graduates is able to meet quality-of-care standards.

While programs of the type enacted in Alabama are not yet being instituted in other states, the trend in the adoption of provisional licensing programs for IMGs, considered alongside the Alabama bridge year program, presages broad changes in the requirements for physician licensure. These changes have the potential to degrade the extant qualifications for medical practice. Laws permitting skilled, experienced IMGs to practice in the US without the often inappropriate burden of further residency training may be a positive development. However, changes in medical licensure requirements have the potential to disrupt a system that has linked postgraduate medical education and physician licensure in this country for the past century. Health care in the US can ill afford a decline in the quality of training that physicians undergo or the quality of care they provide. It is incumbent on our medical schools and graduate education programs to train more physicians, extend the impact of physicians through the expansion of the scope of practice of other health care workers, and reduce physician loss by taking steps to reduce burnout. Augmenting our physician workforce through the lowering of barriers facing IMGs may be a reasonable approach, though it is one that carries with it a negative impact on those physicians’ countries of origin. It also carries a risk to states that reduce licensure requirements for IMGs. The latter recently led members of the Tennessee Medical Board, out of concern regarding the verification processes, to refuse to enforce the new Tennessee law.¹⁷ In concluding, we maintain that there is no substitute for a commitment to high standards through the support of physicians in practice and the system that trains those physicians in the US Lowering barriers to permit the licensure of IMGs and other physicians by individual states may prove a response to workforce shortages that is not in the best long-term interest of patients or the health care enterprise.

• Download figure
• Open in new tab

Figure 1.

Physician density as related to programs for provisional physician licenses.

• Received for publication July 3, 2024.
• Revision received September 13, 2024.
• Revision received September 16, 2024.
• Accepted for publication September 23, 2024.