More States Allow Pathway to Permanent Licensure for Foreign-Trained Docs

Many states have either dropped residency requirements for certain international medical graduates (IMGs) or introduced legislation to enact such changes, opening the door to permanent licensure for more foreign-trained doctors.

In 2023, Tennessee became the first state to eliminate residency requirements — a decision met with significant resistance among key stakeholders. Several members of the Tennessee Board of Medical Examiners raised concerns about patient safety and potential liability. One member even threatened to resign.

By 2024, 15 states had either passed or were considering bills focused on alternative pathways to licensure for IMGs.

As of this month, 19 states have enacted legislation allowing eligible IMGs to obtain full licensure without post-graduate training in North America, and another 23 states have either recently proposed similar bills or have pending legislation, according to data recently released by the Federation of State Medical Boards (FSMB).

In addition, almost every jurisdiction offers an “eminence” pathway for an individual of “distinction” at the discretion of the medical board, the FSMB noted.

Notably, California and New York have an option for IMGs to obtain limited licensure without pursuing additional graduate medical education. Full pathway legislation is also pending in these states.

Jayesh “Jay” Shah, MD, president of the Texas Medical Association, said there are 30 to 40 counties in his state that have no physicians. To that end, the main goal of Texas House Bill 2038, which passed in May 2025, was to increase access to qualified physicians.

Physicians who would take advantage of this pathway have to be highly qualified and meet “stringent requirements” before they’re allowed to practice in the state, he stressed.

“They have to have employment in hand before they can apply for this license. They have to be able to pass their USMLE [U.S. Medical Licensing Exam] 1 and 2. They have to have the ECFMG [Educational Commission for Foreign Medical Graduates] certificate. So there’s a lot of things that they need to do,” he said.

More broadly, these physicians also must have similar residency training in their home countries and a clean license to practice. Moreover, no one will get a full license immediately, Shah noted. “They will have a provisional license, and they will be working with the physician side-by-side who will be evaluating them for 3 years before they can do independent practice.”

The Texas Medical Board announced the rule change in January.

However, there are challenges for doctors seeking alternative pathways. Last year, President Trump issued an executive order to impose a $100,000 application fee on every H-1B visa petition, though legislation has been introduced to waive such fees for physicians and other healthcare workers.

“Hopefully, that will help,” Shah said.

Hao Yu, PhD, a health policy expert at Harvard Medical School in Boston, said there are pros and cons to enacting these laws. On the pro side, state legislatures are eager to address physician shortages. Some rural hospitals have been forced to close due to challenges recruiting physicians. If international physicians were to fill in those workforce gaps, hospitals could avoid closures, Yu explained.

On the con side, there’s huge variation in the quality of medical education in different countries. It’s also possible that patients may not trust IMG physicians and there’s no guarantee that an IMG doctor will choose to work in rural hospitals where physicians are most needed. So far, there aren’t any empirical data to help address that question because of delays in implementing these laws.

“The issue here is, maybe the state legislature is moving quickly, but the state licensing boards are really moving slowly,” Yu said.

“We need to do careful evaluation[s] to make sure, number one, [that] implementing these laws really achieves the intended goal of … increasing physician supply, especially in physician shortage areas, and number two, there’s no difference in terms of healthcare quality between this type of newly licensed physician and the U.S.-trained physician,” he explained.

It will be years before researchers have the data to answer these questions, he added. While Yu said he can’t be certain that every single IMG will perform as well as a U.S.-trained physician, “I believe the vast majority of them will be just doing fine, but … time will tell.”

States that have passed legislation to allow alternative pathways for IMGs include Arkansas, Florida, Idaho, Illinois, Indiana, Iowa, Louisiana, Massachusetts, Minnesota, Nevada, North Carolina, Oklahoma, Oregon, Rhode Island, Tennessee, Texas, Virginia, Washington, and Wisconsin.

Those with proposed or pending legislation include Arizona, California, Connecticut, Georgia, Kansas, Kentucky, Maine, Maryland, Michigan, Mississippi, Missouri, Nebraska, New Hampshire, New Jersey, New York, North Dakota, Ohio, Pennsylvania, South Carolina, Vermont, West Virginia, and Wyoming.