The Growing Nationwide Radiologist Shortage: Current Opportunities and Ongoing Challenges for International Medical Graduate Radiologists

Abstract

The United States is facing shortages in a myriad of medical fields, including diagnostic radiology (DR). The increasing number of imaging studies, owing to advancing technology and an aging population, is outgrowing the capacity of radiologists. However, there have not been effective long-term solutions to manage this issue, which could have a looming effect on patient care and radiology residents’ education. The alternate pathway introduced by the American Board of Radiology (ABR) allows international medical graduates (IMGs) who have completed DR residency outside the U.S. and Canada to be eligible for board certification after 4 additional years of training in the U.S. This eligibility requirement can be met by a combination of fellowships, up to 3 years of residency, and/or faculty appointments at the same time. The criteria were updated in 2022, facilitating the certification process for applicants. The changes included completing the 4 years of training within 8 years instead of the preapproved 4 consecutive years, omitting the obligatory 4 months of nuclear radiology training, and the ability to retrospectively include 2 years of training before the date of application. Considering the lack of reliable, up-to-date data in the literature and to highlight the importance of this pathway for the radiology community, this special report discusses the contribution of IMGs to the different aspects of the health care system in the U.S., with a focus on DR, as well as the newly updated alternate pathway criteria. Potential critical logistic challenges the IMG applicants may face are reviewed. Finally, the report proposes actions that could facilitate the ABR certification process and help integrate these highly qualified IMG radiologists into the American health care system.

© RSNA, 2025

See also the article by Ghosh and Crotty in this issue.

Summary

International medical graduate radiologists who complete the American Board of Radiology alternate pathway offer a valuable resource to help bridge the gap between the high demand and low supply of radiologists in the U.S. workforce.

Essentials

• ■ The United States is facing a radiologist shortage, and the demand for imaging is outpacing the growth in the number of radiologists entering the workforce.

• ■ The American Board of Radiology recently updated its alternate pathway requirements for foreign-trained radiologists, rendering board certification more accessible and flexible.

• ■ International medical graduate radiologists contribute greatly to the practice of radiology in the U.S.; however, they face challenges that radiology stakeholders need to address.

• ■ The certification process can be improved by expediting the visa process, easing licensing requirements, increasing the availability of alternate pathway positions, providing financial aid when needed, mitigating implicit biases, establishing credibility in the process, and building a reliable database of foreign-trained radiologists in the U.S.

Introduction

Diagnostic imaging is a core component of medical practice, and the utility of different imaging modalities has resulted in increased accuracy and timely diagnosis of various diseases, preventing complications and decreasing the overall burden on the health care system, which is especially useful in an emergency setting when imaging turnaround times may delay treatment and disposition (1,2). Owing to the growth of technology in the past decade, in addition to an aging population and increased Medicare enrollment, there has been a substantial increase in the number of diagnostic imaging studies (3). Nonetheless, in most regions, the growth of imaging applications in patient care has outgrown the capacity of radiologists (4). It was reported that the average workload of radiologists in the United States has almost doubled from 14 900 studies to 26 457 studies per year between 2008 and 2018, respectively, while the number of radiologists entering the workforce has increased by only 13% (5).

The imbalance is expected to worsen, according to the Association of American Medical Colleges, especially given that a large portion of the physician workforce is approaching retirement age. By 2034, there will be an estimated shortage of between 37 800 and 124 000 physicians, including thousands of radiologists (6). The challenge is exacerbated by a lack of radiologists in certain subspecialties and an uneven rural distribution. According to a study published in the Journal of the American College of Radiology in 2021 (7), the number of pediatric radiology fellows has been declining, with 44% of fellowship spots remaining unfilled. The deficit in pediatric radiologists is expected to worsen by 38% within 10 years (7).

There have been various approaches to addressing health professional shortages in different countries, particularly in the aftermath of the recent pandemic. Some European countries are increasing their international workforce by easing their licensure requirements for foreign-trained subspecialized physicians (8). Germany offers a special residence title for foreign academics with higher education degrees seeking qualified employment with a concrete job offer, called the European Union Blue Card (9). There has been a rise in the international recruitment of radiologists in the United Kingdom (UK): Forty percent of clinical radiologists recruited in 2019 were foreign-trained (10). The UK and Ireland are the European countries that gain the greatest advantage from the extensive global use of English, resulting in the UK being the most sought-after destination for foreign physicians. In 2020, the National Health Service implemented the medical support worker program to facilitate the employment of refugee and international physicians in the UK. The goal was the short-term recruitment of up to 1000 physicians to alleviate pandemic pressures on the National Health Service. The program provided funding and support for the medical support workers, including a mentoring initiative linking the refugee and international physicians with retired physicians who could give them guidance and advice through the registration process and practice in the UK (11). In addition, during the height of the pandemic, Belgium, the Czech Republic, the UK, Germany, Ireland, Italy, and Spain relaxed the rules and visa requirements for foreign-trained physicians. Urgent temporary licenses to work were provided. These countries also reduced their language requirements for conversion examinations and allowed foreign-trained physicians to register to work in support roles in health care (12). However, it is worth emphasizing that the international recruitment of health care workers in more developed countries may increase the crisis in the countries of origin, which may have limited physician resources as well.

Radiology residents, who will shape the future of the field, will also be impacted by the detrimental effects of the workforce imbalance. A higher volume of cases is crucial to being exposed to a wider variety of disease entities. However, as the workload increases, less time will be allocated to teaching to avoid shortcomings in patient care, which will adversely affect the quality of resident education. Residents will also have more responsibilities that might exceed their capacity, which can result in burnout and a lower quality of life due to mental health strain (13).

In a recent approach in the U.S., there has been an increased role of nonradiologist providers in the interpretation of imaging studies, depending on regional policies, such as nurse practitioners and physician assistants interpreting mostly radiographs and cardiologists interpreting cardiac CT and MRI scans (14,15). A 2023 retrospective study revealed that the rates of diagnostic imaging interpretation by nonphysician practitioners (NPPs) are rising, mostly in rural and small-town areas with less restrictive regulations (16). The extent to which NPPs interpreted images obtained with more advanced imaging modalities was particularly striking. CT and MRI accounted for 21% of the overall NPP-interpreted imaging (16). Although the overall performance of radiologist versus nonradiologist interpreters has not been officially studied, these adjustments are alarming and could negatively impact patient care and radiology residents’ education. Considering the lack of optimal training for interpretation among NPPs, as shown in a prior study (16), as well as the indication-focused interpretation by nonradiologist readers, additional aspects of the studies, such as nonrelated incidental findings, can be undermined.

The shortfall in radiologists has resulted in several attempts to manage this issue, including increasing the number of radiology residency spots and improving radiologist efficiency through the application of artificial intelligence in the workforce (17,18). However, due to limited resources, especially considering the impact of the recent COVID-19 pandemic, there has not been significant success in this matter. The federal government has placed numerous constraints on the Resident Physician Shortage Reduction Act of 2021 by steering much of the granted money toward primary care, mental health, and rural geographic areas. It is unclear how many of these positions may be designated for radiology. Even if radiology is considered, the number would unlikely be sufficient to address the projected needs (6).

The residency matching process is becoming more and more competitive every year. In 2023, the overall number of registered applicants was 48 156, the second highest in the history of the match (19). For the past few years, the number of international medical graduates (IMGs) applying for U.S. residency programs has also increased substantially, with the number of registered non–U.S. citizen IMGs being 10 801 in 2023, which is 707 more than the previous year (19). For all the postgraduate year 1 applicants, there have been almost 40% unmatched IMG applicants as compared with 6% among U.S.-trained physicians (19). Applicants are showing increasing interest in diagnostic radiology (DR), with this specialty being among the top five applied specialties for U.S. MD applicants in 2023 (19). The total number of postgraduate year 2 DR applicants was 2014, and all 1006 available positions were filled in the main match process. Among the matched applicants, 80.5% (810 of 1006), 12.2% (123 of 1006), 2.1% (21 of 1006), and 5.2% (52 of 1006) were U.S. MDs, U.S. doctors of osteopathic medicine (ie, DOs), U.S. IMGs, and non-U.S. IMGs, respectively (19).

Overall, the most recent official data available from the Association of American Medical Colleges reported the number of IMG radiology residents as 576 (13.3%) of 4327 total radiology residents in 2021 (20). As reported by Khoshpouri et al (21), Massachusetts, Pennsylvania, Connecticut, California, and Texas had the largest number of non-U.S. IMGs in radiology residencies, and Arkansas had the highest percentage of DR non-U.S. IMG radiology residents in 2023.

The American Board of Radiology Alternate Pathway

The American Board of Radiology (ABR) offers IMGs who have completed their radiology training outside the U.S. and Canada the opportunity for board certification through the alternate pathway (22). The original criteria for board certification eligibility required 4 consecutive years of radiology training in a single institution with a DR training program approved by the Accreditation Council for Graduate Medical Education or the Royal College of Physicians and Surgeons of Canada. The training could include a combination of fellowship, residency (up to 3 years maximum), or faculty appointment. One year of research was also accepted as one of the 4 years.

The ABR periodically reviews and updates its certification requirements and pathways. The most impactful change happened in November 2022, when ABR updated the criteria for the alternate pathway, indicating eligibility as completion of nonconsecutive 4 years of radiology training within 8 years from the training start date, provided they are completed at the same institution. The ABR governors also opted to forgo the obligatory 4 months of nuclear radiology training. However, candidates who wish to become authorized users of radioactive materials should complete the training to meet the Nuclear Regulatory Commission’s training requirements. In addition, it is now permissible to retrospectively include 2 years of training before the date of application, provided the training took place at the same institution. Furthermore, part-time appointments working more than 0.5 full-time equivalents are allowable, as long as the equivalent of 4 years of training as a 1.0 full-time equivalent is completed within 8 years from the training start date (22). The new updated criteria give the trainees more flexibility in completing the requirements. Per the information provided by the ABR executives by direct contact, the pathway had certified 103 candidates by 2019 over a period of approximately 10 years. As of January 2024, 275 candidates are enrolled in the pathway. While this is clearly an upward trend, there are no available data for annual rates on pathway enrollment and completion, to our knowledge.

Current and Prospective Contribution of IMGs

Overall, IMGs constitute approximately 25% of practicing physicians in the U.S., as reported by the Association of American Medical Colleges, with the highest percentage per state reported in New Jersey (38%), New York (37%), Florida (36%), Illinois (31%), and Connecticut (30%) (Table 1) (23). Based on a 2018 report by the American Immigration Council, foreign-trained physicians contribute substantially to aiding lower-income and disadvantaged communities in the U.S. (24). The report showed that more than half (53%) of all foreign-trained physicians work in areas where the population has a per-capita annual income of $30 000 or less, and a higher proportion of physicians treating low-income patients are trained overseas. Additionally, the percentage of foreign-trained physicians serving the U.S. population with 30.1%–100% poverty, $0–$15 000 per-capita annual income, and 0%–10% with college degree is reported as 31.6%, 42.5%, and 31.3%, respectively (24).

Table 1:

State- or District-specific Percentage of Active Physicians Who Are International Medical Graduates per the Association of American Medical Colleges (2021)

According to a 2021 American Medical Association report, there are currently 2924 IMG radiologists (10.8%) practicing in the U.S. of 27 197 total practicing radiologists (25). IMGs practicing radiology in the U.S. include those who finished radiology residency in their home countries with a strong clinical background, as well as recent graduates who usually pursue research before applying for radiology residency. IMGs offer diverse experiences in health care systems around the world, which can provide fresh perspectives and innovative approaches to solving clinical and research questions. Their knowledge about conditions in different patient populations can contribute to a broader understanding of a variety of diseases and their imaging patterns. Considering the difficulties IMGs may experience during their educational path, they often demonstrate a high level of adaptability and resilience. Four additional years of subspecialty training for these applicants further increase their expertise and familiarize them with the health care system in the U.S.

IMG radiologists represent a valuable resource that can help bridge the gap between high imaging demand and low supply of radiologists. Their expertise and commitment to advancing the field have resulted in more involvement in academic positions as well as on editorial committees for high-ranking radiology journals and radiologic societies, such as Academic Radiology and the RSNA. For instance, 20% of the editorial board members (10 of 50) for RadioGraphics are IMGs, with 12% (six of 50) having completed fellowship programs in the U.S. for board certification (26). Similarly, the editorial board of the Journal of the American College of Radiology consists of approximately 38 members with MD degrees, among whom 16% (six of 38) are IMGs (27).

The shortage of radiologists in rural areas is particularly noticeable. These underserved areas often require a general radiologist to be familiar with a broad range of pathologic abnormalities, the task for which IMG radiologists may be particularly well-suited, considering the 4 years of subspecialty training in the alternate pathway. Finally, IMGs may positively contribute to U.S. resident education. As many available radiology fellowship training positions go unfilled, the ABR alternate pathway offers a unique opportunity to provide well-qualified fellows who contribute to residents’ education, ease the burden on faculty, promote diversity, and ultimately build a reliable pipeline of future radiologists (28).

Challenges and Opportunities for IMGs

Most of the IMG applicants to the ABR alternate pathway require a J-1 or H-1B visa to start their training, with J-1 being more feasible. Based on the immigration status, the visa has to be renewed annually or every few years. The J-1 visa is a temporary, nonimmigrant exchange visa that is exclusively sponsored by the Educational Commission for Foreign Medical Graduates. The J-1 visa has restrictions, including a prohibition on moonlighting and a 7-year maximum stay in the U.S. Subsequently, physicians are mandated to return to their foreign countries of residence for 2 years or apply for a J-1 waiver while working in an underserved area, which can be challenging given the geographic constraints and limited availability. The H-1B visa is a 6-year temporary specialty occupation visa that has no 2-year home residency requirement. H-1B visa holders can apply for an adjustment of status, which converts an H-1B visa to an employment-based green card, making it a more attractive option for physicians. However, given the significant costs and lengthy processing times, this visa option is less commonly offered by sponsoring programs (28,29).

The number of facilities offering the alternate pathway is relatively limited, with additional facilities accepting applicants on a case-by-case basis, and some offering yearly renewal of the contracts based on the availability of a fellowship spot. The uncertainty about securing fellowship positions traditionally steered IMGs away from the alternate pathway in exchange for a more secure residency spot (30).

According to the Federation of State Medical Boards, each state has different requirements for initial medical licensure. All states’ licensing jurisdictions require IMGs to complete 1–3 years of postgraduate medical training in the U.S. (Table 2). Some states, including Alabama, North Dakota, Maine, and Kansas, require the training to be accredited by the Accreditation Council for Graduate Medical Education. Certain states mandate a restriction on the maximum number of attempts allowed for the U.S. Medical Licensing Examination, or USMLE. For example, Arkansas mandates a maximum of three attempts for USMLE step 3, whereas Arizona imposes no restrictions (31). Owing to the COVID-19 pandemic and the ongoing armed conflicts in parts of the world, the process by which some IMGs verified their licenses at international medical schools has been disrupted, further complicating this challenging process (30).

Table 2:

State- or District-specific Requirements for International Medical Graduates to Obtain Initial Medical Licensure per the Federation of State Medical Boards

IMGs find the high-quality training in the U.S. a chance to expand their careers and explore new opportunities. In some instances, this journey is associated with possible socioeconomic challenges. Some of the obstacles may be related to the financial burden, communication issues, variations in clinical practice, and difficulties interacting with specific categories of patients because of local societal values. Communication, including a lack of English proficiency, has been reported as one of the most frequent challenges identified in studies evaluating the transition of immigrant physicians into the U.S. health system (30).

Despite the support for the vast majority of IMGs pursuing clinical and scholarly activities in the U.S. (32), implicit bias exists in society, including among health care professionals (33). However, there is no official recognition or objective data about the impact of this bias.

Different fields have been reducing the barriers to having more international workers in the U.S. For instance, as shown in a recent study, between 2000 and 2019, the overall number of science, technology, engineering, and math (ie, STEM) workers in the U.S. increased by 44%, from 7.5 million to more than 10.8 million (34). This would not have been possible without the support and sponsorship of the employers.

Some states, including Tennessee and Alabama, are implementing a new law allowing IMGs to bypass U.S. residency training and enter into practice as licensed physicians (35). However, there are limitations to this law, including commitment to a single state for the duration of the entire career. Additionally, it may take years to establish the effectiveness of this plan in practice and its generalizability to other states.

The recent modifications implemented by the ABR governors to the requirements for DR certification pose an instructive step in the right direction. Offering the option to complete training in 8 nonconsecutive years, along with the flexibility of retrospectively adding 2 years of training, relieves the pressure of securing a preapproved plan with four consecutive fellowships beforehand, which was often a major barrier for IMGs applying to the alternate pathway. With the current change of policy and extended years of completion of fellowships, yearly offers will be less problematic for the applicants and the programs. On the other hand, it is important to note that implementing changes to address the ongoing shortage of radiologists, including the ABR alternate pathway, necessitates a thorough analysis of health care policies, regularly updated job market data, and implementation of measures to balance supply and demand and prevent overstaffing in the future.

A Call to Action for Lawmakers and Radiologic Stakeholders

To address some of the challenges that IMG radiologists face when seeking the ABR alternate pathway, the radiology community is urged to advocate for legislative changes that would create a more welcoming environment for foreign-trained radiologists. These suggested measures are as follows.

Simplifying and expediting visa processes.—The Commission on Government Relations of the American College of Radiology, as well as health care executives, may consider discussing the current situation to push for an expedited and more secure visa process. Justification from these committees to lawmakers may allow the passage of legislative actions that could include alleviating some of the impeding J-1 visa requirements, such as the 2-year mandatory foreign residence and waiver requirement, or offering a special visa or residence title similar to the European Union Blue Card. Radiologic societies and legislative bodies can collaborate to allot funds to graduate medical education, which will encourage universities to issue the more desirable H-1B visa to IMGs applying to the ABR alternate pathway.

Easing licensing requirements.—Given the recent disruptions caused by the pandemic and the ongoing global armed conflicts, the American Medical Association recently urged state licensing boards and other credentialing institutions to accept certification from the Educational Commission for Foreign Medical Graduates as verification rather than requiring documents directly from international medical schools. This could provide an impactful tool to address the challenge (36).

Increasing the availability of positions.—Increasing awareness and encouraging institutes in more rural, underserved areas to adopt the ABR alternate pathway can provide a pivotal solution to the uneven geographic physician distribution. Moreover, recruiting IMG radiologists into struggling subspecialties can assist with addressing the shortfalls in those areas. One additional proposed way to encourage immigrant physicians could be by awarding them green cards after a few years of service in medically underserved areas (37).

Providing financial aid.—Sponsoring programs can help ease the burden on IMG radiologists relocating to the U.S. by offering financial assistance or compensatory subsidies for living expenses, health insurance coverage for them and their families, as well as educational, visa, and licensure expenses.

Mitigating implicit bias.—Institutional strategies to address implicit biases are integral to the acquisition and retention of IMG radiologists seeking the alternate pathway. Programs can offer complimentary orientation courses and resources to ease the transition to a new culture in the U.S. There is limited knowledge on how to conduct effective bias training given that different countries of origin and educational backgrounds lead to varied perceptions and challenges. However, research indicates that reducing the negative effects of prejudices requires comprehensive training that should focus on team building, personal reflection, and self-awareness (33).

Establishing credibility.—Taking into account the availability of fellowship spots and ensuring that clinical and professional competencies are maintained, the 4-year plan of the alternate pathway should be as clear and binding as a residency. Building trust will ensure the maintenance of a reliable pipeline of future foreign-trained radiologists.

Building a reliable database.—Knowledge is power. Addressing challenges facing IMG radiologists heavily relies on projections and estimations. The lack of active data collection and updated statistical analysis substantially impedes moving forward to implement meaningful policies and monitor the effectiveness of interventions. The value of foreign-trained radiologists remains outdated and theoretical without hard up-to-date statistics. Radiologic stakeholders are urged to create a reliable database of the numeric and geographic distribution of foreign-trained radiologists practicing in the U.S., as well as annually updated objective reports of their challenges with and contributions to health care.

Limitations

There is a lack of a reliable specialty-specific database for foreign-trained radiologists in the U.S., including the type of practice, as well as an absence of current statistics on applicants and institutes offering the ABR alternate pathway. Due to ABR’s recent implementation of revised requirements, no accurate data are available regarding the impact of the recent changes on the number of applicants and the success rates of achieving board certification through this pathway. Future studies may be performed to evaluate the performance of the radiologists board-certified through the alternate pathway.

Conclusion

The U.S. is facing a shortage of medical professionals, including radiologists. Many attempts have been made to address this issue, most of which are short-term or suboptimal solutions. Considering the high interest of international medical graduate (IMG) radiologists in pursuing radiology in the U.S., a more fundamental approach can be considered. Embracing the diversity and expertise that IMGs bring to radiology can lead to improved patient care, enhanced research endeavors, and a more comprehensive understanding of medical imaging practices worldwide. The American Board of Radiology (ABR) alternate pathway allows this highly qualified workforce to be eligible for radiology board certification after 4 years of training. The new changes adopted by ABR represent a major step forward, but there is still a long way to go. Acquiring and retaining IMG radiologists calls for the collaborative action of various radiologic societies and other stakeholders involved to push for legislative alterations and budget allocations that would support academic institutes in their pursuit of the alternate pathway.