A growing number of states have made it easier for doctors who trained in other countries to get medical licenses, a shift supporters say could ease physician shortages in rural areas.
The changes involve residency programs — the supervised, hands-on training experience that doctors must complete after graduating medical school. Until recently, every state required physicians who completed a residency or similar training abroad to repeat the process in the U.S. before obtaining a full medical license.
Since 2023, at least nine states have dropped this requirement for some doctors with international training, according to the Federation of State Medical Boards. More than a dozen other states are considering similar legislation.
About 26% of doctors who practice in the U.S. were born elsewhere, according to the Migration Policy Institute. They need federal visas to live in the U.S., plus state licenses to practice medicine.
Proponents of the new laws say qualified doctors shouldn’t have to spend years completing a second residency training. Opponents worry about patient safety and doubt the licensing change will ease the doctor shortage.
Lawmakers in Republican- and Democratic-leaning states have approved the idea at a time when many other immigration-related programs are under attack. They include Florida, Iowa, Idaho, Illinois, Louisiana, Massachusetts, Tennessee, Virginia, and Wisconsin.
President Donald Trump has defended a federal visa program that many foreign doctors rely on, but they could still be hampered by his broad efforts to tighten immigration rules.
Supporters of the new licensing laws include Zalmai Afzali, an internal medicine doctor who finished medical school and a residency program in Afghanistan before fleeing the Taliban and coming to the U.S. in 2001.
He said most physicians trained elsewhere would be happy to work in rural or other underserved areas.
“I would go anywhere as long as they let me work,” said Afzali, who now treats patients who live in rural areas and small cities in northeastern Virginia. “I missed being a physician. I missed what I did.”
It took Afzali 12 years to obtain copies of his diploma and transcript, study for exams, and finish a three-year U.S.-based residency program before he could be fully licensed to practice as a doctor in his new country.
But a commission of national health organizations questions whether loosening residency requirements for foreign-trained doctors would ease the shortage. Doctors in these programs could still face licensing and employment barriers, it wrote in a report that makes recommendations without taking a stance on such legislation.
Erin Fraher, a health policy professor at the University of North Carolina who advises the commission and studies the issue, said lawmakers who support the changes predict they will boost the rural health workforce. But it’s unclear whether that will happen, she said, because the programs are just getting started.
“I think the potential is there, but we need to see how this pans out,” Fraher said.
Afzali struggled to support his family while trying to get his medical license. His jobs included working at a department store for $7.25 an hour and administering chemotherapy for $20 an hour. Afzali said nurse practitioners at the latter job had less training than him but earned nearly four times as much.
“I do not know how I did it,” he said. “I mean, you get really depressed.”
Many of the state bills to ease residency requirements have been based on model legislation from the Cicero Institute, a conservative think tank that sent representatives to testify to legislatures after proposing such programs in 2020.
The new pathways are open only to internationally trained physicians who meet certain conditions. Common requirements include working as a physician for several years after graduating from a medical school and residency program with similar rigor to those found in the U.S. They also must pass the standard three-part exam that all physicians take to become licensed in the U.S.
Those who qualify are granted a restricted license to practice, and most states require them to do so under supervision of another physician. They can receive full licensure after several years.
About 10 of the laws or bills also require the doctors to work for several years in a rural or underserved area.
But states without this requirement, such as Tennessee, may not see an impact in rural areas, researchers from Harvard Medical School and Rand Corp. argued in the New England Journal of Medicine. In addition to including that condition, states could offer incentives to rural hospitals that agree to hire doctors from the new training pathways, they wrote.
Lawmakers, physicians, and health organizations that oppose the changes say there are better ways to safely increase the number of rural doctors.
Barbara Parker is a registered nurse and former Republican lawmaker in Arizona, where the legislature is considering a bill for at least the fourth year in a row.
“It’s a really poor answer to the doctor shortage,” said Parker, who voted against the legislation last year.
Parker said making it easier for foreign-trained physicians to practice in the U.S. would unethically poach doctors from countries with greater health care needs. And she said she doubts that all international residencies are on par with those in the U.S. and worries that granting licenses to physicians who trained in them could lead to poor care for patients.
She is also concerned that hospitals are trying to save money by recruiting internationally trained doctors over those trained in the U.S. The former often will accept lower pay, Parker said.
“This is driven by corporate greed,” she said.
Parker said better ways to increase the number of rural doctors include raising pay, expanding loan repayment programs for those who practice in rural areas, and creating accelerated training for nurse practitioners and physician assistants who want to become doctors.
The advisory commission — recently formed by the Federation of State Medical Boards, the Accreditation Council for Graduate Medical Education, and Intealth, a nonprofit that evaluates international medical schools and their graduates — published its recommendations to help lawmakers and medical boards make sure these new pathways are safe and effective.
The commission and Fraher said state medical boards should collect data on the new rules, such as how many doctors participate, what their specialties are, and where they work once they gain their full licenses. The results could be compared with other methods of easing the rural doctor shortage, such as adding residency programs at rural hospitals.
“What is the benefit of this particular pathway relative to other levers that they have?” Fraher said.
The commission noted that while state medical boards can rely on an outside organization that evaluates the strength of foreign medical schools, there isn’t a similar rating for residency programs. Such an effort is expected to launch in mid-2025, the commission said.
The group also said states should require supervising physicians to evaluate participants before they’re granted a full license.
Afzali, the physician from Afghanistan, said some internationally trained primary care doctors have more training than their U.S. counterparts, because they had to practice procedures that are done only by specialists in the U.S.
But he agreed with the commission’s recommendation that states require doctors who did residencies abroad to have supervision while they hold a provisional license. That would help ensure patient safety while also helping the physicians adjust to cultural differences and learn the technical side of the U.S. health system, such as billing and electronic health records, the commission wrote.
Fraher noted that doctors in programs with supervision requirements need to find an experienced colleague with the time and interest in providing this oversight at a health facility willing to hire them.
The commission pointed out other potential hurdles, such as malpractice insurers possibly declining to cover physicians who obtain state licenses without completing a U.S. residency. The commission and the American Board of Medical Specialties also pointed to the issue of specialty certification, which is managed by national organizations that have their own residency requirements.
Physicians who aren’t eligible to take board exams could lose out on employment opportunities, and patients might have concerns about their qualifications, the board wrote. But it said a majority of its member boards would consider certifying these doctors if states added requirements it recommended.
Lawmakers’ plans to use these new licensing pathways to increase the number of rural doctors will require the foreign-trained doctors to navigate all these obstacles and unknowns, Fraher said.
“There’s a lot of things that need to happen to make this a reality,” she said.
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