Opening the Door Wider to International Medical Graduates: The Significance of A New Law in Tennessee

International medical graduates (IMGs) play a large role in the U.S. healthcare system, comprising 1 in 4 physicians (24.7%) in the U.S. Despite their critical role in boosting the U.S. physician supply and mitigating physician shortages in underserved areas¹, IMGs face substantial barriers to licensing compared to domestic graduates, hindering their efforts to practice medicine in the U.S. A new groundbreaking law enacted in Tennessee may help reduce these barriers and expand opportunities for IMGs to practice medicine in the U.S. This Perspective first summarizes existing barriers facing IMGs, then highlights significant changes of Tennessee’s new law from current programs before discussing potential concerns about the new policy.

There are two major requirements for IMGs to be licensed to practice in the U.S. First, all IMGs, regardless of their U.S. citizenship status, must complete a U.S.-based residency even if they have previously completed a residency and/or practiced medicine in another country. While the mandated US-based residency training intends to standardize training quality, it presumes that IMGs received substandard training overseas and causes duplicative clinical training with unclear benefit to their skills and competencies. Moreover, a fraction of IMGs has difficulty completing training due to financial or social instability, with some abandoning training altogether. Second, even after completing a US-residency program, noncitizen IMGs often experience difficulties in securing necessary visas to practice medicine because few hospitals are willing to sponsor H1B visas due to filling fees, especially after the 2016 Medicare cuts to graduate medical education.² Historically, noncitizen IMGs enter the U.S. through the J-1 medical trainee visa program and are only able to remain in the country after their post-graduate medical training through the Conrad 30 waiver program or another J-1 waiver program.³ These exemptions allow IMGs to convert their J-1 to a H1B visa in exchange for an obligation to practice in health professional shortage areas (HPSAs) or medically underserved areas.

Together, these two barriers have led to substantial underutilization of IMGs’ medical skills. Recent evidence indicates that up to 40% of immigrants with medical and doctorate degrees work in jobs not requiring those degrees.⁴ The “deskilling” of highly skilled immigrants, including IMGs, costs $39 billion in lost wages annually and $10 billion in unrealized taxes among the entire labor force each year.⁵

Significance of Tennessee’s New Law

In April 2023, Tennessee, through SB 1451 that aimed to mitigate the state’s physician shortage, drastically reduced these barriers and became the first state in the nation to allow IMGs who are licensed in another country to be provisionally licensed and practice in the U.S. without requiring completion of a U.S.-based residency. Applicants must be certified by the Educational Commission for Foreign Medical Graduates (ECFMG), pass US licensing exams (USMLE Step 1 and Step 2), and have completed at least a three-year residency program at an accredited international program. They must then practice under the supervision of a Tennessee-licensed physician for two years before receiving an unrestricted license.

Tennessee’s new law offers a new “provisional licensing” pathway for IMGs (PLIMGs) to attain fully licensed physician status, similar to the programs for IMGs in Canada and the United Kingdom, both of which have implemented PLIMG programs in the past three decades. Similar bills pending in Arizona, Idaho, Missouri, and Nevada seek to emulate the PLIMG pathway to address the perceived or objectively assessed physician shortage in their states. Tennessee’s new law also removes major restrictions imposed by previous immigration policies and allows greater flexibility for individual hospitals to hire IMGs, especially noncitizens.

Table 1 highlights key differences between Tennessee’s new law and the current IMG policies in the U.S., including:

Table 1.

Comparing Current IMG Policy and Tennessee’s New Law

	Current IMG Policy	Tennessee’s New Law
Eligibility	Any International Medical Graduates (IMGs) regardless of level of previous training	IMGs who have completed a three-year postgraduate training program outside the US or have practiced as a physician for at least three of the past five years
Required Tests	Complete USMLE Step 1 and Step 2	Complete USMLE Step 1 and Step 2
Required Certification	ECFMG Certification Required	ECFMG Certification Required
Required US Residency Training	Yes	No
Visa Requirements for Non-Citizens	Predominantly J-1 (sponsored by ECFMG), with some H1B (sponsored by individual hospitals); must return to country of origin upon expiration of 2-year J-1 visa at end of postgraduate medical training	H1B sponsored by individual hospitals
Available Positions for Non-Citizens	30 per state per year through the Conrad 30 waiver program for noncitizen IMGs; very limited availability of H1B hospital sponsorship visas for noncitizen IMGs	No restriction
Requirements for Sponsoring Hospitals and IMGs	Hospital must have ACGME Accredited Residency Program; IMG must be enrolled in the residency program	Hospital must have ACGME Accredited Residency Program; IMG does not need to be enrolled in the residency program
Time to Achieve Full U.S. License	Traditional Length of Residency/ Fellowship training (3+ years)	Two years of provisional license
Type of Licensure	Trainee license before obtaining a full license	Provisionally licensed before obtaining a full license
Scope of Practice	Trainee	Provisional, Supervised
Clinical Quality Standards	Must meet core clinical competencies from ACGME requirements	At individual hospital discretion
Salary	Standardized post-graduate salaries which varies by hospital	Varies by hospital without standardization
Practice Specialty	States determine specialty eligibility, with most prioritizing primary care physicians and psychiatrists through the Conrad 30 waiver program	No specific requirements, at hospital discretion
Practice Location Requirements	Health Professional Shortage Area/ Medically Underserved Area or Population as designated by HRSA through the Conrad 30 waiver program’s visa requirements	No restriction

• Not requiring eligible IMGs to enter the National Resident Matching Program, participate in the U.S. medical residency system, or meet core competencies set forth by the Accreditation Council for Graduate Medical Education (ACGME).

• Shortening the licensing pathway from three or more years of residency/fellowship training to a two-year provisional licensing period.

• Replacing trainee licenses with provisional licenses during IMGs’ two-year trial period.

• Providing flexibility for noncitizen IMGs regarding specialty choice, practice location, and available positions, which are currently determined by individual states through the Conrad 30 waiver program.³

While this new law creates an effective framework to recruit well-selected IMGs and increase physician supply, Tennessee and other states contemplating similar legislation should consider several modifications to ensure that the legislation can achieve its intended effect of improving access to quality care in shortage areas.

Strengthening Tennessee’s New Law

Prior research has found that IMGs are more likely to practice as primary care physicians in rural areas and staff critical access hospitals relative to U.S. graduates, hence filling vital roles in safety-net and underserved communities.^1,6 However, it is uncertain whether PLIMGs offered by Tennessee’s new law will reduce shortages in the state’s underserved areas. The IMGs recruited by the Conrad 30 program are required to practice in shortage areas. Without a similar requirement, PLIMGs’ likelihood of practicing in underserved areas may decline, mirroring the trend among U.S. medical graduates. If similar legislation is adopted in other states, IMGs may preferentially choose provisional licensing pathways over J-1 waiver programs, potentially limiting these programs’ ability to recruit physicians to shortage areas. Furthermore, the Tennessee law requires PLIMGs to work in a hospital with an ACGME accredited residency program during their two years of supervision. However, of the 9 accredited internal medicine residencies in Tennessee, 7 are in cities with more than 100,000 residents thus limiting training opportunities in rural areas. Tennessee policymakers may offer monetary incentives especially for rural hospitals to provide visa sponsorship for PLIMGs. They can also utilize the PLIMG pathway to strengthen partnerships between academic medical centers and smaller rural hospitals exposing PLIMGs to diverse patient populations. Once PLIMGs are fully board-licensed, states should use recruitment and retainment incentives including HPSA obligations or monetary compensation in exchange for rural service. These would help distribute physicians to areas where they are needed most in accordance with legislative intent.

Quality of care remains an important component for hospitals and states to consider when implementing legislation like Tennessee’s new law. For PLIMGs, heterogeneity in both the quality of training acquired abroad and the supervision received in the U.S. might erode care quality, especially in low resourced settings. The Tennessee law requires sponsoring hospitals to have ACGME residency accreditation without detailed requirements to ensure quality of supervision that PLIMGs may receive during the two-year provisional licensing period. With multiple states considering PLIMGs, national standardization of licensing requirements similar to ACGME competencies for residents could provide an important avenue for ensuring adequacy of clinical skills. Since medical licensing boards currently require ECFMG certification for IMGs to obtain an unrestricted license, Tennessee hospitals and state medical boards need to work with the ECFMG to create core competencies for PLIMGs to successfully transition to an unrestricted licensure, mimicking ACGME. This would help ensure candidate mastery and demonstration of the necessary clinical skills and competencies, while encouraging hospitals to support the continued medical education of their PLIMGs.

Another important consideration is PLIMG worker protections, which the Tennessee law does not explicitly address. To prevent PLIMG underpayment, Tennessee policymakers should require hospitals to set standard PLIMG salaries, considering their years of experience akin to Postgraduate level. Previously described penalties for resigning and harsh working conditions for newly immigrated clinicians should be addressed by hospitals so that PLIMGs’ working conditions are similar to U.S. graduates.

Overall, Tennessee’s new law offers a model to attract IMGs to practice in the U.S. However, additional efforts are needed to strengthen the law and achieve the legislative intent of alleviating physician shortage in underserved areas. Further research should evaluate how the new law may affect global medical ‘brain drain,’ employee compensation, and visa sponsorships.