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Nine states—and a dozen more soon—now allow internationally trained physicians to bypass full US residencies, seeking to mitigate rural physician shortages.
To address persistent physician shortages in rural America, at least nine states have relaxed rules since 2023 that previously required internationally educated physicians to complete full US residency training before obtaining an unrestricted license. Additionally, another dozen legislatures are considering comparable bills, according to the Federation of State Medical Boards.
Scope & Scale of the Policy Shift
The impact could be substantial: according to a Migration Policy Institute report, slightly more than one-quarter of practicing US physicians are foreign-born. Model legislation drafted by the Cicero Institute serves as a reference for several state bills aimed at loosening regulations. These bills apply solely to foreign-trained physicians who meet requirements such as working as a doctor for a certain number of years after medical school graduation or participating in a residency program that meets US residency program standards. Additionally, foreign-born physicians must pass the three-part United States Medical Licensing Examination, after which they receive a restricted practice license that requires completion of a period of supervised service. Obtaining full licensure takes several more years, and approximately 10 of the bills mandate that physicians work in rural or underserved communities.
The Advisory Commission on Additional Licensing Models (ACALM) has explored the efficacy of relaxing residency requirements for internationally trained physicians and argues that doing so would not eliminate all of the current licensing and employment roadblocks for such individuals. ACALM Advisor Erin Fraher, PhD, explained that changing requirements for foreign-trained physicians may be a smart move, but the true test will be whether these reforms are actually increasing the physician workforce in rural communities.
Advocates See Redundancy in Retraining
Proponents argue that forcing seasoned clinicians to undergo duplicate training squanders scarce talent. Internist Zalmai Afzali, MD, —who finished medical school and a residency program in Afghanistan before immigrating to the US in 2001—spent 12 years securing full US licensure. According to Dr. Afzali, the majority of foreign-born physicians would welcome the opportunity to work in rural areas, provided they could continue practicing medicine.
Skeptics Cite Safety & Equity Concerns
Critics have expressed concern for patient safety and questioned whether these new rules will ameliorate the physician shortage issue. Some, including registered nurse Barbara Parker, assert that loosening the rules for foreign-trained physicians would lead to the US luring doctors away from other countries that have a greater need for licensed physicians, and may encourage hospitals to favor lower-paid foreign graduates. Parker also warns that inadequate vetting of some international residency programs could expose US patients to substandard care. She favors alternative strategies—higher rural salaries and expanded loan-repayment programs—to draw domestic clinicians without compromising oversight.
Toward a Balanced Framework
ACALM anticipates that an outside organization committed to assessing the quality of foreign residency programs will be launched soon. Such organizations already exist to evaluate the quality of foreign medical schools. Furthermore, ACALM recommends that states require supervising doctors to assess foreign-trained physicians before they receive full licensure. Ideally, physicians and lawmakers will ultimately create a framework that simultaneously respects the expertise of internationally trained doctors and delivers sustainable, high-quality care to the communities that need it most.
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