In a desire to quickly increase the supply of physicians, multiple US states have passed or are pursuing legislation to allow international medical school graduates (IMGs) to obtain full licensure without completion of an ACGME-accredited residency. In the Featured Plenary “Physician Workforce Shortage: How States Are Responding” at the 2025 ACGME Annual Educational Conference, speakers explored the workforce pressures that have prompted these legislative initiatives and resulting legislative actions.
The panel of speakers represented organizations that form the Advisory Commission on Alternate Pathways for State Licensure of International Medical Graduates – the ACGME, Intealth, and the Federation of State Medical Boards (FSMB). The guidance developed by the Advisory Commission will provide state medical boards with a uniform approach to implementing the various laws through regulation, as well as help lawmakers considering such legislation to develop a more consistent approach to increasing access to physician care, while protecting both patients and candidates for licensure.
In describing the current state of the physician workforce, FSMB President and Chief Executive Officer Humayun Chaudhry, DO, MACP, FRCP said that although the workforce has grown in absolute number, it is “maldistributed,” adding pressure for legislators to seek solutions through such legislation.
Erin P. Fraher, PhD, MPP, director of the Program on Health Workforce Research & Policy at the University of North Carolina at Chapel Hill, described types of maldistribution, such as those that affect individual states, motivating them individually to act.
“What you may be feeling in Montana may be very different from what you’re feeling in Nevada,” she said, noting that the combination of population moving south and graduate medical education (GME) funding tilting north has exacerbated the maldistribution.
She also discussed maldistribution in underserved areas. “The fact that our physician supply is increasing… doesn’t mean those rural areas are getting access to care or access to physicians,” she said, noting that most GME funding goes to hospitals while only two percent goes to rural – based on formulas calculated in the 1980s.
The discussion segued into how IMGs fit into this picture and how IMGs will fill the shortages – both by geography and by specialty. ACGME Chief Communications and Public Policy Officer John R. Combes, MD noted that roughly 30 states have passed or are currently working on legislation to create alternate pathways for IMGs to be licensed locally.
“Some of the laws don’t even make sense,” said Dr. Chaudhry, arguing that the medical community was not fully engaged by lawmakers in crafting some of the legislation. He cited an example that several laws do not require the candidates to have completed a residency, which is a “significant departure from what we’ve done in the United States for decades.” However, he added that the state boards will have some “wiggle room” as they are tasked with implementing new legislation. For instance, although the various state-led pathways require a supervised environment period, they are often not delineated in the legislation themselves.
One major issue with much of the legislation passed by individual states is the lack of a data collection requirement, which makes it difficult to gauge the success of programs and where improvements can be made. Dr. Combes noted that the legislation currently being debated in Kentucky has a clear mandate for data collection, which is one of the recommendations made by the Commission, indicating that “legislators are listening.”
As the speakers continued their discussion alongside comments and questions from the audience, one key concern was funding. They noted that almost no states have really thought about the funding piece of the picture, with Maine being the only state with a fairly limited proposal on the table. Other areas of concern include “brain drain” for “donating” locales – which is not limited to countries but also underserved areas in the US.
Intealth Chief Executive Officer Eric Holmboe, MD, MACP, FRCP reminded the audience that the journey taken by IMGs is not easy, and involves not just rigorous exams and training, but also cultural and linguistic integration, as well as acquisition of visas and other documentation. It is the latter where IMGs may be taken advantage of, he cautioned.
Dr. Chaudhry added that much of the legislation may be well intentioned, especially in alleviating the rural physician shortage, but reminded the audience that if IMGs receive unrestricted licenses through a pathway, they are essentially free agents. “Recruitment is easier than retention,” he noted.
On next steps, the speakers said that additional recommendations from the Advisory Commission, which will be essential to supplement the initial recommendations, are anticipated later in 2025 to address other important areas, such as the criteria or assurances that should be required for a physician to transition from provisional to full and unrestricted licensure.