San Antonio radiologist Rajeev Suri, MD, immigrated to the U.S. over two decades ago to further specialize in interventional radiology after completing a residency program in India.
Despite receiving what he considered an “exceptional education” from his residency program, however, Dr. Suri was obligated to undergo residency training a second time in America – at a program accredited by the Accreditation Council for Graduate Medical Education (ACGME) – to meet U.S. licensure requirements necessary for international medical graduates (IMGs).
Nonetheless, Dr. Suri says he was still one of the “lucky few IMGs” to continue his medical career at all following his move to the U.S. In America, the availability of residency training positions is heavily influenced by federal policies that limit the number of residency slots that qualify for Medicare funding, affecting both U.S. and international medical graduates.
“Acquiring a residency position is a very competitive process, especially for those seeking to immigrate to the United States,” the chair-elect of the Texas Medical Association’s International Medical Graduate Section said. In 2023, the “match saw almost 43,000 applicants for only 40,000 residency positions. There are just not enough spots to accommodate the wide range of students applying for residency.”
During the 2024 Main Residency Match of the National Resident Matching Program (NRMP), 4,100 of the 10,000 non-U.S. citizen medical students and graduates who applied for residency positions were not successful in securing a match during Match Week. This applicant group was the largest to go unmatched, according to NRMP.
Dr. Suri says a lack of residency spots can have long-standing negative impacts on the medical careers of IMGs seeking to practice in the U.S.
“I am happy I could continue my medical career in this country. Not all internationally trained physicians are able to do so,” Dr. Suri said.
Some solutions, however, may be on the horizon to both reduce barriers to practice for IMGs and to address physician shortages across the country.
A handful of states, including Texas, and national entities, are examining means for IMGs to enter the American health care workforce via alternative pathways to practice.
For example, the Federation of State Medical Boards (FSMB), Intealth, and ACGME in March established a new Advisory Commission on Alternate Licensing Models to evaluate potential alternative pathways for state licensure of physicians who have completed training and/or practiced outside of the U.S.
The council was created in part to address a lack of standardized processes for IMG licensure.
“While there are some shared characteristics among the [state] proposals, there are also distinctions that may lead to varying outcomes across states and create confusion among physicians, regulators, and patients. In some cases, it is also unclear how medical boards and regulators will operationalize the proposed pathways,” FSMB stated of the council’s creation in a press release.
These pathways may aid Texas in the fight to provide care to its underserved areas, Dr. Suri says. The state is projected to have a current shortage of 20,420 doctors, across all specialties, per an April 2024 report by the nonpartisan policy organization Cicero Institute.
Moreover, a May 2022 report by the Texas Department of State Health Services indicates shortages across all primary care specialties are projected to continue into 2032.
TMA’s current policy supports requiring one year of graduate medical education (GME) for graduates of U.S. and Canadian medical schools and two years for international medical graduates.
However, supporters of alternative licensure pathways say reducing residency requirements can help solve physician shortages in underserved areas while halting scope of practice creep.
“There’s no doubt the primary care shortage is going to get worse over the next few years. So, the question at that point is, how do you fill that gap?” Dr. Suri said. “Do you expand scope of practice to [advance practice registered] nurse practitioners and physician assistants or would you rather allow a fully trained physician to care for patients? I would prefer the latter.”
International hurdles
Internationally trained physicians comprise 25% of the physician workforce in the U.S., according to a January 2022 American Medical Association toolkit. However, pathways for international graduates to practice in the U.S. are fraught with challenges.
For one, federal immigration laws include a specific pathway to practice for IMGs who obtain residency training in the U.S. The federal J-1 Educational Exchange Visa program is available to those intending to receive GME or training from an approved program, among other educational, research, and learning opportunities, per the U.S. Citizenship and Immigration Service.
In addition, upon completion of training in the U.S., J-1 visa holders must then return to their home country for a period of two years to transmit the knowledge they gained to their community, according to the U.S. Department of State. An individual must fulfill this obligation before being eligible for a change or adjustment of visa status.
The only exception to the two-year home residence requirement of the J-1 visa program is to receive a waiver that allows physicians to forgo the two year-waiting period if they commit to a practice in a medically underserved area in the U.S. for three years.
Proponents of waiver programs say the requirement provides care to vulnerable populations.
Dr. Suri says the solution has its own challenges. For example, he points to one of the most common waiver programs that allows J-1 foreign medical graduates, if accepted, to waive the two-year foreign residence requirement: the Conrad 30.
Under the Conrad 30 program, each state is allocated 30 waivers per year that exempt J-1 physicians from the requirement to return to their country of origin in exchange for three years of service in an underserved community. However, the program allows each state to run its own program, with its own application deadlines, requirements, and processes.
Without a national standard, Dr. Suri says IMGs are forced to comply with “all and every” requirement.
In March 2023, solutions to the program’s issues were presented to the U.S. Senate via the Conrad State 30 and Physician Access Reauthorization Act. The act, if passed, would modify the Conrad 30 Waiver program to increase state allocations to 35 physicians per year, extend the program’s length, and provide flexibility to expand the number of waivers in states where demand exceeds limit.
Moreover, the Department of Health and Human Services (HHS) changed its waiver program guidelines in June 2020 to allow any health care facility, from hospital to private practice, to apply for an HHS waiver for foreign physicians if the facility has a health professional shortage area score of at least seven and if the physician will provide primary care treatment at that facility.
This means that unlike the Conrad 30 program, HHS waivers do not carry a prohibitive quota and timeline, increasing availability to internationally trained physicians who did not qualify under Conrad’s strict guidelines.
Dr. Suri says changes to the waiver process are “welcome, if properly evaluated. We must examine if changes to these programs are improving the quality of care that we provide.”
Academic nuances
Current requirements placed upon IMGs still aim to ensure the quality of care delivered by internationally trained physicians meets national standards, Dr. Suri says.
However, “they are still restrictive,” he said.
IMGs who seek to practice medicine in the U.S. must still demonstrate an adequate understanding of the U.S. health care delivery system via the completion of residency training at an American or Canadian program with required accreditation – as specified by the medical licensing laws in each state – regardless of having completed residency training in their countries of origin.
To do this, IMGs must first become certified by the Educational Commission for Foreign Medical Graduates (ECFMG).
ECFMG is the credentialing agency for non-U.S. physicians and graduates who seek to practice in the United States or apply to a U.S. medical residency program – now a division of Intealth, a nonprofit that coordinates medical education resources to support the education and training of health care professionals.
The amount of time it takes to complete this process can vary depending on the student, per ECFMG, before they can apply to a U.S. residency program.
From there, the ECFMG certificate requires IMGs to pass steps one and two of the United States Medical Licensing Examination (USMLE), the same exam U.S. allopathic medical school graduates are required to pass. IMGs must then comply with several additional requirements, including passing step three of USMLE, to be eligible for a Texas medical license.
Dr. Suri says because the process for standardized accreditations of foreign medical schools is still evolving, confusion among IMGs persists.
Without an international accreditation process that assesses the equivalency of medical education in other countries to those in the U.S. and Canada, state medical boards and physician credentialing programs in the U.S. are challenged to evaluate the medical education of IMGs themselves.
However, changes to this process may soon positively affect IMGs.
ECFMG plans to launch its Recognized Accreditation Policy in late 2024, which will require the accrediting agencies of foreign medical schools to be recognized by an external quality assurance organization that has been reviewed and approved by Intealth.
Per ECFMG, the policy “fosters global accreditation efforts and promotes harmonized standards for evaluating undergraduate medical education worldwide. It is one of the many ways that Intealth is working to advance quality in health care education worldwide in order to improve health care for all.”
Potential for change
Other changes at the state level seek to address workforce challenges by reducing or eliminating the requirement for IMGs to attend a U.S. residency program at all.
Tennessee passed a law in 2023 to allow IMGs to practice with a provisional license without requiring U.S. or Canadian medical residency training.
Under the new law, IMGs must have completed three years of training, a post-graduate program in the country they are licensed in or have practiced in a medical capacity for at least three of the last five years. They are also required to have a job offer from a health care facility that has a residency program accredited by ACGME.
After a two-year provisional license, IMGs may become eligible for a full medical license to practice general medicine in Tennessee. However, it is unknown whether these physicians would be able to practice anywhere other than Tennessee.
Moreover, Dr. Suri has uncertainties about employing physicians who follow this pathway, and their ability to qualify for board certification or meet the credentialing requirements for health care facilities or health plans.
“We need to ensure that we do not decrease the quality of care we provide to our patients,” he said. “If these allowances are made so IMGs can practice in underserved areas, we need to evaluate if we’re actually setting ourselves back by reducing the quality of care in those areas.”
Since Tennessee’s law came to pass, legislation targeting IMG licensing has been introduced in eight other states: Alabama, Arizona, Iowa, Massachusetts, Missouri, Nevada, Vermont, and Wisconsin.
Texas is examining its own solutions.
In 2011, House Bill 1380 reduced residency training requirements for IMGs from three to two years to help international physicians meet national specialty board certification exam schedules. The previous residency requirement of three years created difficulties for IMGs to meet the board certification exam schedule, pushing some IMGs to train in other states.
Additionally, House Bill 5074, introduced March 10, 2023, sought to provide a provisional license to foreign medical program graduates, among other additives.
These licenses would have been given to those who:
• Are licensed in good standing to practice medicine;
• Have a medical degree (or substantially similar degree) by a foreign medical education program determined to be in good standing in accordance with Texas Medical Board rule;
• Completed a residency program in their country of licensure;
• Have a proficiency in the English language;
• Are authorized under federal law to work in the U.S.;
• Meet USMLE exam requirements; and
• Have been offered employment in Texas as a physician by a health care facility.
While the bill did not pass, Dr. Suri believes the 2025 legislative session, starting in January, will see similar legislation, especially as national organizations like FSMB aim to come up with their own solutions.
At press time, FSMB had not made its official recommendations. The organization also did not immediately respond to requests for comment.
While Dr. Suri is hopeful these solutions may prove beneficial, he also worries that until a national standard is set, these pathways may become burdensome for IMGs to navigate.
He says that when he becomes the chair of TMA’s International Medical Graduate Section next year, he will work in collaboration with other appropriate TMA groups to consider solutions to burdens that plague IMGs.
“There’s no replacement for U.S. training. but we can evaluate the potential for changes to meet the needs of our country’s health care workforce,” Dr. Suri said.