Regulatory Requirements | 05.28.25
Additional Pathways to State Licensure for IMGs
By Liz Ingraham, Matthew Shick, JD
The regulatory landscape for internationally trained physicians (ITPs) is changing rapidly, as more states recognize their potential to address health workforce needs and are developing streamlined pathways to licensure. A thorough understanding of both traditional and emerging regulatory frameworks is essential for those responsible for evaluating the qualifications of physicians. This article highlights ongoing licensure changes and provides resources for those who want to learn more and follow these important developments.
IMGs in U.S. Healthcare
International medical graduates (IMGs) are physicians who receive their medical education outside the United States and are critically important to U.S. healthcare. According to the AAMC’s 2023 U.S. Physician Workforce Data, IMGs comprise approximately one-quarter of all actively licensed physicians in the U.S. As shown by Awad Ahmed, et al., among other studies, IMGs fill important workforce gaps, frequently caring for patients in underserved areas and practicing in medical specialties with physician shortages, especially primary-care specialties such as Family Medicine and Pediatrics.
The Traditional U.S. Licensure Pathway for IMGs
The traditional pathway to U.S. licensure for IMGs starts with ECFMG certification. This rigorous evaluation sets requirements for the IMG’s international medical school and medical education; requires an IMG to pass certain U.S. licensing exams; possess clinical skills and demonstrate English language proficiency; and verifies the authenticity of the IMG’s medical school diploma directly with the issuing medical school.
ECFMG certification is a prerequisite for another important milestone in the traditional licensure pathway for IMGs: training in an accredited U.S. program of graduate medical education (GME). While the specific duration of U.S. training required varies by state, this requirement has applied to all IMG applicants, including those who have trained and practiced outside the United States.
The Rise of Additional Licensing Pathways
In recent years, a number of states have developed additional licensing pathways for international physicians. While these additional pathways vary significantly by state, there are common themes.
First, these additional pathways typically are for “internationally trained physicians” or “ITPs”, i.e., those who have completed GME training, achieved licensure, and practiced medicine outside the United States. Second, the additional pathways do not require training in accredited U.S. GME. There also is a common goal across many states — to address U.S. healthcare workforce shortages, especially in rural and underserved areas, through streamlined licensure pathways.
Twelve states have enacted laws allowing qualifying ITPs to obtain full licensure without completing accredited U.S. GME programs. These states include: Arkansas, Florida, Iowa, Idaho, Illinois, Indiana, Louisiana, Massachusetts, Oklahoma, Tennessee, Virginia, and Wisconsin. An additional 22 states have introduced or are considering similar legislation.
Advisory Commission on Additional Licensing Models
The Advisory Commission on Additional Licensing Models was established in late 2023 in response to growing interest among states in additional licensure pathways. Co-founded by Intealth, the Federation of State Medical Boards (FSMB), and ACGME, the Advisory Commission’s goal is to provide recommendations to state medical boards, state legislators, policymakers, and others in the development and/or implementation of laws specific to the licensing of physicians who have already trained and practiced medicine outside the United States.
The Advisory Commission convenes experts in physician assessment, training, and licensure, adding a national perspective to the dialogues underway in many states. The commission neither endorses nor opposes the additional pathways but rather aims to suggest appropriate safeguards to states that pursue them.
In early 2025, the Advisory Commission issued its initial guidance to states in the form of nine recommendations. This first set of recommendations is focused on eligibility requirements and related considerations for entry by an ITP into an additional licensure pathway. This initial guidance includes the recommendation that ITPs continue to obtain ECFMG certification and the assurances it provides to the U.S. medical community and to patients. It also calls for successful completion of a period of supervision and assessment to transition from provisional licensure to full licensure.
What’s Next?
We can expect more developments as states continue to pursue legislation to add licensure pathways.
Issues that could impact the effectiveness of such pathways should be considered. For example, U.S. federal immigration and visa requirements will impact the practical ability of physicians who are not U.S. citizens or permanent U.S. residents to utilize additional pathways. Furthermore, the ubiquity of specialty-board certification as a key factor in employment, hospital privileging, and insurance panel inclusion decisions is likely to impact the efficacy of non-traditional licensing pathways.
Finally, the Advisory Commission work continues, with additional recommendations expected later in 2025. This additional guidance is expected to address the assessment and supervisory elements during the period of provisional licensure for ITPs in additional pathways.
Resources
- Listen to the NAMSS Tomorrow’s MSP® Podcast, S2, Episode 2: Additional Pathways to State Licensure for IMGs
- Learn more about ECFMG Certification here.
- Find the Advisory Commission on Additional Licensing Models Guidance Document here.
- View a map of states with enacted and proposed additional pathway legislation.
Liz Ingraham
Liz is assistant vice president for external relations and public affairs at Intealth, where she works to advance the organization’s public policy agenda, with particular focus on advocating for international medical graduates (IMGs) and the vital role they play in U.S. health care. In this role, Liz engages with a variety of stakeholders; conducts policy analysis; advises senior and executive leadership; and develops content that shares Intealth’s expertise and recommendations in academic medicine and health care policy. Her prior roles at Intealth include assistant vice president for communications and external affairs, where she was responsible for corporate communications for Intealth and its divisions, ECFMG and FAIMER, including publications, websites, social media, branding, and media relations. Liz’s undergraduate education at Drew University was in German and Russian languages. Her graduate education at Rice University was in Theoretical Linguistics and Semiotics. She is a Fellow of LEADERSHIP Philadelphia.
Matthew Shick, JD
Matthew is assistant vice president and chief government relations officer at Intealth, where he leads the organization’s efforts to advocate for international medical graduates (IMGs) and the essential contributions they make to U.S. health care. In this role, Matthew manages the organization’s relationships with local, state, and federal government entities; shapes legislation and regulatory initiatives related to the health workforce, medical education, and immigration; advises Intealth’s executive leadership; and represents the IMG community’s interests to policy makers and government officials. Prior to joining Intealth, Matthew served as senior director of government relations and regulatory affairs at the Association of American Medical Colleges (AAMC), where he was responsible for legislative and regulatory policy and advocacy related to diversity, health equity, immigration, the physician workforce, higher education, and veteran affairs. Matthew holds a B.S. in Biology from Georgetown University and a J.D. from George Mason University School of Law.