Addressing Physician Shortages in the United States With Novel Legislation to Bypass Traditional Training Pathways: The Fine Print

In the United States, there are shortages of physicians in specific specialties and locations that are expected to get worse. The latest 2023 Association of American Medical Colleges workforce models predict a shortage of physicians by 2036 between 13 500 and 86 000.¹ Physician communities with the highest likelihood to show shortfalls are primary care (20 200 to 40 400 physicians) and surgical specialties (10 100 to 19 900 physicians).¹ Specific drivers of these shortages include a projected 8.4% increase in the US population, an aging population (with a 34.1% increase in the number of Americans >65 years) by 2036, and an aging physician workforce, with over a third of physicians expected to retire in the next decade.¹

Recently, lawmakers, state, and federal officials have sought to alleviate this challenge, with at least 15 states² introducing a flurry of legislative interventions, creating novel pathways to practice. These changes use 2 predominant tactics to address the physician gap: (1) mobilizing domestic physician workforce “reservoirs” to create pathways toward independent practice that may apply to international medical graduates (IMGs) and US medical graduates (USMGs); and (2) strategies to “bypass” traditional graduate education tracks, allowing IMGs to practice independently without completing graduate medical education (GME) programs in the United States. Figures 1, 2, and 3 illustrate some of these novel pathways; additional pathways are described in online supplementary data Figures 1 and 2. Online supplementary data Table 1 summarizes examples of proposed or enacted legislative strategies and provides a preliminary workforce analysis for each while online supplementary data Table 2 provides specific examples of legislation and respective analyses.

Figure 1.

Mobilization of US Domestic Workforce: Creation of Bridge Year Designed for Unmatched Domestic Medical School Graduates

Note: Example legislation: Alabama bridge year physician limited permit HB243, 2023.

Figure 2.

Mobilization of US Domestic Workforce: Recognize International Medical School Experience Into Supervised, Limited Term Practice

Note: Example legislation: Washington HB1129, 2021-2022.

Figure 3.

Bypass Traditional GME Tracks: Recognize Foreign GME Experience Into Supervised Practice Tracks, Leading to Independent Practice

Abbreviations: GME, graduate medical education; IMG, international medical graduate.

Note: Example legislation: Tennessee HB1312, 2023.

Challenges and Considerations of Current Reform Efforts

All the currently passed laws share the goal of increasing the physician pool and enhancing the public’s access to health care. However, while strategies of domestic workforce mobilization present the advantage of preserving traditional competency-based GME training, IMG bypass pathways present unique challenges and opportunities. These pathways created by legislators currently lack specificity on the processes and structures to assure the attainment of the entrustable skills, knowledge, and attitudes required for safe, high-quality, independent practice—representing an important opportunity for medical educators to take a seat at the table, defining the “fine print.”

Finding the Way Forward

The Box describes the pertinent operational and regulatory considerations of these proposed GME bypass tracks. Clearly, the answers to these will significantly impact the level of confidence that such bypass programs can equitably and reliably address the health needs of the US population. Below, we posit some critical domains for consideration for medical education and health system stakeholders.

Box Considerations for GME “Bypass” Tracks for International Medical Graduates

Operational/Institution Level Considerations

How does the health service provider ensure quality of program outcomes?

What are the learning objectives of the program and how do they align with the intended scope of practice?

What are the governance structures for these programs (eg, program director, faculty, committees)?

What are the specific skills, behaviors, and knowledge that are expected of candidates, and how are these assessed? Is the duration of supervised practice sufficient to assess competencies attained?

What are the requirements of supervisors (eg, preparation and credentials to supervise, regularity of oversight) and assessment standards, and what levels of autonomy are appropriate?

What is the role/scope of these physicians, and how does this affect the clinical learning environment?

How are these physicians credentialed? What are the medicolegal frameworks of practice relevant to these physicians?

Regulatory/System-Level Considerations

What does this mean for the undergraduate to postgraduate continuum? Can domestic medical students opt out of structured GME programs and pathways to pursue these foreshortened pathways to licensure? How will the presence of these bypass programs affect the learning environment for domestic medical students and medical graduates?

What are the implications for board eligibility? Do the boards have a role in standardizing educational outcomes? How will competence be validated/reassessed once in practice? (eg, Will there be a corollary to maintenance of certification?)

What are the social/ethical implications of this workforce (eg, equitable access to programs, equitable renumeration, potential scope overlap, acculturation to patient/social constructs of practice)?

What new funding is required? How are the costs of assessing clinical competence, supervision, education, and remediation of trainees accounted for? Will funding be left to hospitals, or will there be local/federal government support of these programs? What are the implications of funding models adopted?

Abbreviation: GME, graduate medical education.

“Bypass” Track Eligibility

Just as aligning medical school educational outcomes to entry requirements for residency is key, so too is clarifying and optimizing the entry requirements to these bypass GME pathways.^3,4 Currently, IMGs entering bypass pathways to independent practice require Educational Commission for Foreign Medical Graduates (ECFMG) certification which, in turn, requires passing the United States Medical Licensing Examination (USMLE) Steps 1 and 2, among other criteria. Though these examinations have validity evidence for the purpose of testing medical knowledge required for licensure, they do not have validity evidence for predicting performance in residency or in future independent practice.⁵ Accordingly, using ECFMG certification as a significant determinant of eligibility for bypass pathways for IMGs poses the same limited assessment of future success as it does for extant, conventional programs. Therefore, while ECFMG certification may represent the “floor” of requirements for entry and currently provides the only standardized assessment of entry medical knowledge, additional holistic assessment of academic preparedness will likely be needed. Also, as with lessons learned from the domestic Match,⁶ harmonizing entry and selection processes and criteria for “bypass” pathways is critical to ensure equitable allocation and coordinated approaches among and between states.

Competency-Based Education

Current global efforts in GME reform may also be helpful to prequalify or prioritize IMG candidates for “bypass” pathways. Many of these efforts have focused on transforming physician training programs to become competency-based instead of time-based,^7,8 with the adoption of accreditation standards serving as an important driver for this change. For example, ACGME International (ACGME-I) accredits global institutions and programs that use its competency-based framework to advance the quality of GME. At the time of writing this article, 23 sponsoring institutions, representing 253 training programs across 13 countries, have received ACGME-I accreditation.⁹ Though the number of trainees in these may not satisfy US workforce needs, IMGs from these programs who pursue bypass pathways are more likely to have demonstrated comparable educational outcomes to USMGs and may more easily adapt to US practice expectations.

Alternatively, states should consider implementing work-based assessments within these bypass tracks. Implementing this competency-based approach in these bypass programs would provide a consensus framework for health service providers to implement and assess the readiness of IMGs in these pathways toward independent practice. This would require significant operational capacity and academic resources. Additionally, the learning needs of these physicians differ significantly from graduates of domestic medical schools. In our opinion, teaching and assessment frameworks should reflect these differences. For example, since these physicians have completed GME programs abroad and may have practiced many years in their home nations, curricular time devoted to medical knowledge competencies may be reduced, while—given their lack of experience with the US practice environment—more emphasis may be placed on competencies like systems-based practice and communication and interpersonal skills. Curricular needs and assessment frameworks will need to be carefully incorporated into individual state-based legislation.

Regulatory and Governance Issues

Regulatory frameworks and clear governance are needed to address medicolegal, pay, practice scope, and other pertinent operational aspects of these programs. Ideally, these efforts should be led or coordinated with national bodies to safeguard rights and representation across the country and to prevent the formation of a “shadow” health care workforce.

Societal and Professional Dynamics

From a global perspective, as physician shortages persist, countries often find themselves competing to retain their workforces. Nations with the highest burdens of disease have the lowest workforce availability, with deleterious effects on access and quality of care.¹⁰ These reforms will likely expand existent geographic workforce imbalances. Taking a more domestic lens, given the uncertainty of the size of this impending pool of IMGs entering the workforce, the dynamics created by potential overlapping practice scopes with other advanced practice providers and health professionals is yet to be understood. Increased competition for clinical positions is likely to occur. Essentially, because current state legislature approaches are clearly focused on immediate fixes to workforce challenges through mass import of physicians, they may exacerbate global inequities regarding access to care. Also, they do not address underlying domestic challenges that create continued supply and demand mismatch. These challenges include GME specialty allocations that are determined independent of population health needs, geographic maldistribution of specialty due to market and other practice drivers, inequitable access to care, state laws, and practice models that influence physician migration, among others.^11-13

Next Steps

These new pathways to practice offer promise as novel, paradigm-changing programs but also pose considerable uncertainty if not addressed collectively with state legislatures, licensing bodies, medical educators, accreditors, and other educational stakeholders. Next steps will likely include the development of novel processes and frameworks, the leveraging of existing expertise and experience, and the adaption of fit-for-purpose strategies to address the unique needs of these physician learners. The GME community must recognize its role as a vested partner with policymakers. Within our respective settings, we must seek opportunities to lend expertise to these changes. By engaging with local state licensure bodies, co-creating organizational policies and programs, and/or informing educational regulators and accrediting bodies, we must lean in.

Editor’s Note

The online supplementary data contains additional pathways, legislative strategies, and examples of legislation.