Navigating State Medical Licensure: A Comprehensive Guide for International Medical Graduates (IMGs)

International Medical Graduates (IMGs) are pivotal to the U.S. healthcare system, comprising over 25% of the physician workforce. In recent years, IMGs have shown progress in securing U.S. residency positions, with the match rate climbing from 44% in 2016 to 62% in 2023. This increase is attributed to both the growth in available residency slots and the diminishing competition from U.S. medical graduates. 

IMGs continue to demonstrate their resilience and adaptability, overcoming diverse challenges to meet the stringent requirements of the U.S. healthcare system. This toolkit is crafted to assist IMGs in navigating the complexities of practicing medicine in the U.S.

Understanding Medical Licensure in the U.S.

Many IMGs believe that passing the Educational Commission for Foreign Medical Graduates (ECFMG) exams and securing a U.S. residency grants an automatic medical license valid across all U.S. states. This is a common misconception; the reality involves more complex criteria for obtaining an unrestricted medical license in the U.S.

All U.S. states mandate that graduates from foreign medical schools complete at least one year of accredited graduate medical education in the U.S. or Canada before becoming eligible for licensure. The duration of required accredited graduate medical education varies: 12 states demand two years, while 25 states require three years.

There are approximately 70 licensing jurisdictions due to some states having separate boards for MD (Doctor of Medicine) and DO (Doctor of Osteopathic Medicine) licensure, each with its own application process, requirements, and dues.

Despite variations, all states require proof of education, training, and completion of licensure exams.

While there is some uniformity in the application process through the Federation Credentials Verification Service (FCVS), established by the Federation of State Medical Boards (FSMB), all states consider the following factors:

• Seven- or Ten-Year Rule

States require that applicants pass all three parts of the United States Medical Licensing Examination (USMLE) within a period of seven to ten years. Exemptions may apply to candidates with additional degrees such as MD/PhD, MD/MPH, or MD/JD.

• Number of Attempts

The number of attempts an applicant makes to pass the various steps of the USMLE also impacts their application. If an applicant fails any exam more than twice, it raises concerns for the authorities.

• Primary Source Verification

Authorities will contact the institutions from which applicants graduated and the directors of their residency programs. Obtaining a response from medical schools can be challenging.

• Completeness and Accuracy

If the primary source verification uncovers an event not disclosed in the application, this could lead to the denial of a medical license. This includes even minor incidents that the applicant may have overlooked or forgotten.

The IMG’s Roadmap to Medical Licensure in the U.S.

When applying for residency in the United States, IMGs face specific requirements:

• Educational Credentials: IMGs must have completed their medical education at a recognized and accredited medical school. Their educational credentials must be verified by the Educational Commission for Foreign Medical Graduates (ECFMG).

• ECFMG Certification: This certification requires passing the USMLE Step 1, Step 2 Clinical Knowledge (CK), and Step 2 Clinical Skills (CS) exams.

• Residency Application: IMGs need to submit their educational background, clinical experiences, personal statement, letters of recommendation, and USMLE scores, among other documents.

• State Medical License: After successfully matching into a residency program, IMGs must obtain a medical license in the state where they will train.

• Visa Requirements: The most common visa for residency training is the J-1 visa, sponsored by the ECFMG.

AMGs have their information automatically uploaded to their FCVS profiles by their medical schools and residency or fellowship programs. IMGs are encouraged to utilize FCVS, as it is recognized by all medical boards for providing primary source verified information. This simplifies the process considerably. 

The Federation of State Medical Boards provides a comprehensive guide on the pathway to medical licensure in the U.S., including detailed definitions and requirements. IMGs can find specific licensure requirements for each state by consulting resources like the “Initial Licensure of U.S. Medical Graduates and International Medical Graduates” provided by FSMB.

ECFMG Certification Requirement 2024

Individual medical schools will no longer be recognized by the ECFMG. Instead, medical schools must be recognized by their country’s national or regional accrediting agency, which in turn must be recognized by the World Federation of Medical Education (WFME).

If a country’s accrediting agency is not WFME-approved by the beginning of 2024, students from medical schools in that country will be ineligible to apply for ECFMG certification.

This change affects not only medical students but also practicing physicians. For instance, a physician who graduated in 2016 from a school currently recognized by the World Directory of Medical Schools can apply for ECFMG certification now. However, from 2024 onwards, if their medical school is not accredited by a WFME-recognized national accrediting agency, they will no longer be eligible for certification, even if they were previously.

The ECFMG announced that the accreditation status of applicants’ medical schools will be included in the Electronic Residency Application Service (ERAS) and visible to residency program directors.

If You’re an IMG

Your first action should be to visit the World Federation of Medical Education (WFME) website. Check if your country’s accrediting agency is recognized or is in the process of being recognized by the WFME.

• If your country’s accrediting agency is recognized and your medical school is accredited by this agency, the 2024 changes shouldn’t affect you.

• If your accrediting agency isn’t recognized or if your medical school isn’t accredited, you need to take steps now to secure your ability to practice in the U.S. in the future.

If your country’s accrediting agency is not currently recognized apply for ECFMG certification as soon as possible — being eligible to apply now doesn’t guarantee eligibility after the 2024 changes.

Obtaining ECFMG certification is just the beginning. You will still need to pass USMLE Step 1, ace Step 2 CK, and create a persuasive application.

Top IMG-Friendly States

Geographical location plays a significant role for IMGs seeking U.S. residency. It’s important to research individual residency programs and be aware of state-specific limitations and the overall “IMG friendliness” of each state.

The top 12 states for IMGs are:

1. New York
2. Florida
3. Pennsylvania
4. Michigan
5. New Jersey
6. Texas
7. California
8. Illinois
9. Ohio
10. Massachusetts
11. Connecticut
12. Georgia

Based on the number of IMGs who matched to a residency program in that state through the 2023 NRMP Main Residency Match.

While many states didn’t see significant changes in the number of IMGs, others experienced notable shifts. New Hampshire, for instance, saw a 158% increase in IMGs. In contrast, Vermont experienced an 80% decrease. The top 12 states for IMGs have remained mostly consistent since 2022, with Georgia newly entering the list at the 12th position, replacing Maryland.

Beyond residency opportunities, IMGs must also consider state-specific licensure requirements, which can vary widely and impact their ability to practice medicine in a particular state. 

It is important to check the latest information and verify the requirements for the Licensure of International Medical Graduates (IMGs) for each state that you are interested in.

New-Era U.S. State Policies and Initiatives for IMGs

Recent developments in the U.S. are indicating a positive shift towards accommodating International Medical Graduates (IMGs), with several states introducing new programs and laws to ease their integration into the medical workforce.

Northern Border Regional Commission’s Visa Initiative

The J-1 Visa Waiver Program simplifies visa requirements for physicians trained in the U.S. who commit to working in health professional shortage areas and medically underserved areas in Maine, New Hampshire, New York, and Vermont for three years, full-time.

This program is set to impact 56 counties in the region, potentially involving over 200 healthcare facilities.

Tennessee’s New Law

Governor Bill Lee of Tennessee signed a law on April 6, allowing international medical graduates to bypass U.S. residency training. To qualify, they must demonstrate competency to the state’s medical board, have completed three years of training or a post-graduate program in their licensed country, and have at least three years of medical practice in the last five years.

Applicants can receive temporary licensure and, if in good standing after two years, may apply for a full, unrestricted license.

Explore a detailed overview of the recent amendments to the eligibility requirements for international medical graduates to practice medicine in Tennessee.

Alabama’s Physician Workforce Act

Governor Kay Ivey of Alabama signed the Physician Workforce Act to address physician shortages. This law creates an apprenticeship-like program for medical school graduates awaiting residency placements.

Illinois’ Legislative Changes

Illinois’ omnibus Medicaid budget bill enables the Illinois Department of Financial and Professional Regulation (IDFPR) to issue limited licenses to IMGs licensed in their home countries, allowing them to practice under direct supervision in Illinois.

A permanent pathway to full licensure for IMGs, starting January 2025, replaces the residency requirement with two years of limited practice under supervision in areas with unmet medical needs. An ombudsman position within IDFPR will assist IMGs in the relicensing process.

The Benefits of Medical Licensing Services for IMGs

Medical licensing services provide expert assistance in understanding and fulfilling the diverse requirements of different state medical boards. This support is invaluable in navigating the often complex and varied licensure processes across states.

These services expedite the licensing process by handling the bureaucratic and administrative tasks.

• One of the biggest challenges for IMGs is the verification of international credentials. Licensing services specialize in this area, ensuring that all documentation meets the specific standards required by U.S. medical boards.

• With the evolving ECFMG certification requirements, particularly those coming into effect in 2024, these services provide essential guidance to ensure IMGs meet the new standards without delays or complications.

• By efficiently managing licensure applications in multiple states, these services open up a wider range of job opportunities for IMGs, allowing them to consider various geographical locations and healthcare settings.

At MedicalLicensing.com, we firmly believe that swift and successful licensure is essential for International Medical Graduates to promptly integrate into the U.S. healthcare workforce, allowing them to contribute their valuable skills in areas where they are most needed.

Summing Up

As IMGs contribute significantly to the U.S. physician workforce, understanding the nuances of medical licensure, adapting to changes in certification requirements, and leveraging state-specific programs are essential for success. The shifts in policies and the introduction of new laws in various states, such as the easing of visa requirements and alternative pathways to licensure, reflect a growing recognition of the value that IMGs bring to healthcare, particularly in underserved areas.

IMGs are encouraged to stay informed, proactive, and adaptable as they navigate this complex but rewarding journey. With diligent preparation, awareness of the evolving medical landscape, and utilization of available resources, IMGs can achieve their goal of practicing medicine in the U.S., thereby enriching the diversity and quality of healthcare services nationwide.