Useful Books and Websites for IMGs
These books and websites are a must read for anyone who wants to improve their life and careerΒ
A world-class thinker counts the 100 waysΒ in which humans behave irrationally, showing us what we can do to recognize and minimize these βthinking errorsβ to make better decisions and have a better life
Useful Books and Websites for IMGs
These books and websites are a must read for anyone who wants to improve their life and careerΒ
A presentation about Alternative IMG Pathways to work in the US without residency trainingΒ
New State Medical Licenses for International Medical Graduates
Practice Without U.S. Residency Requirement
A Revolutionary Change in Medical Licensing β’ 2024-2025
π Overview: Game-Changing Legislation
Major Development: Multiple U.S. states have enacted groundbreaking legislation allowing International Medical Graduates (IMGs) to practice medicine without completing a U.S. residency program.
- 13+ states have passed or are implementing new IMG licensing pathways
- These laws address critical physician shortages, especially in rural and underserved areas
- IMGs can now obtain provisional licenses based on international training and experience
- Pathways to full licensure available after supervised practice periods
β° Timeline
2024: First states implemented programs β’ January 2025: Major expansion with multiple states launching programs
πΊοΈ States with Active Programs (2024-2025)
π΄ Florida
Eliminates U.S. residency requirement for internationally trained physicians with 4+ years of active practice.
π΅ Tennessee
First state to pass legislation. Provisional license for internationally trained physicians.
ποΈ Idaho
Provisional license with 500 hours supervised clinical experience requirement.
π½ Iowa
5+ years of post-residency practice required. Focus on rural and underserved areas.
ποΈ Illinois
Limited license pathway with 2-year supervision period before full licensure.
π§ Wisconsin
Provisional license with 5+ years of international practice experience required.
ποΈ More States Joining the Movement
π΅ Arizona
Focus on counties with <1 million population. Requires USMLE Steps 1 & 2.
𦬠Colorado
Re-entry license for IMGs with board evaluations and educational programs.
π¬ Virginia
Provisional license for 5+ years foreign practice with ECFMG certification.
π² Washington
Limited license for IMGs nominated by state departments, valid for 2 years.
βοΈ Louisiana
Provisional license after 3 years of supervised practice leads to permanent license.
π Arkansas
Full licensure after 2 years of practice under academic license.
π Common Requirements Across States
State Medical Board (SMB) Recommendations: Current standardized requirements emerging across states for new IMG pathways.
π Educational Requirements
- Medical degree from internationally recognized medical school
- School must be listed in World Directory of Medical Schools
- ECFMG certification and graduation from recognized medical school
- Evidence of substantially similar post-graduate training based on national standards
π Examination Requirements
- USMLE Step 1 and Step 2 CK passage (required by SMBs)
- Some states require USMLE Step 3
- English proficiency demonstration
π₯ Training & Experience
- Unrestricted license to practice medicine in another country
- At least 3 years of experience in full-time practice (SMB recommendation)
- No longer than 2 years out of clinical practice
- Good standing with home country medical authorities
πΌ Employment & Supervision
- Offer of employment from appropriate medical facility prior to application
- Minimum 2-year period of temporary provisional licensure
- Supervision by board-certified physician of same specialty
- Valid immigration status allowing medical practice
π£οΈ ECFMG Certification & Pathways
Key Update: ECFMG has introduced new Pathways for clinical and communication skills assessment, replacing the discontinued Step 2 CS exam.
ECFMG Certification Requirements (2025)
- Medical Science: Pass USMLE Step 1 and Step 2 CK
- Clinical Skills: Complete an ECFMG Pathway
- Communication Skills: Satisfactory score on Occupational English Test (OET) Medicine
- Credentials: Medical school verification through ECFMG
π€οΈ ECFMG Pathways (6 Options)
- Pathway 1: Currently licensed to practice medicine in another country
- Pathway 2-5: Various clinical experience and training requirements
- Pathway 6: Clinical evaluation by licensed physicians using Mini-CEX
Note: Pathways have expiration dates and may need revalidation for ongoing certification.
π States with IMG Provisional Licenses for Experienced International Graduates
Focus: These states specifically target internationally trained physicians with significant practice experience, distinct from programs for recent U.S. medical graduates.
β States with Active IMG Programs (2024-2025)
π΄ Florida
Target: Physicians with 4+ years active international practice
Key Feature: Eliminates U.S. residency requirement entirely
π΅ Tennessee
Target: IMGs with international training and ECFMG certification
Key Feature: First state to pass IMG-specific legislation
ποΈ Idaho
Target: IMGs with 3+ years residency abroad
Key Feature: 500 hours supervised clinical experience requirement
π½ Iowa
Target: IMGs with 5+ years post-residency practice
Key Feature: Focus on rural and underserved areas
ποΈ Illinois
Target: Licensed IMGs from home countries
Key Feature: 2-year supervision period before full licensure
π§ Wisconsin
Target: IMGs with 5+ years international practice
Key Feature: 3-year supervised practice pathway
π Additional States with IMG Programs
Recently Enacted or Starting Soon
- π΅ Arizona: Counties <1M population, USMLE Steps 1&2 required (Jan 2025)
- π¬ Virginia: 5+ years foreign practice, ECFMG certification (April 2024)
- βοΈ Louisiana: 3-year supervised practice β permanent license (2025)
- 𦬠Colorado: Re-entry license with board evaluations (2024)
- π² Washington: Limited license, 2-year validity with renewal option
π Key Statistics
Total States: 11+ states with active or launching IMG provisional programs
Target Population: Estimated 40% of IMGs currently working in non-medical roles
Primary Focus: Rural and underserved areas facing critical physician shortages
π¨ββοΈ Do IMGs Need a Supervising Physician Before Applying?
Critical Question: Whether IMGs must secure employment and supervision arrangements before or after license application varies significantly by state.
π Application Requirements by State
π’ Employment Offer Required BEFORE Application
States: Arizona, Iowa, Wisconsin, Illinois
Requirement: Must have job offer from approved healthcare facility prior to license application
Process: Find job β Apply for license β Begin supervision
βοΈ Supervision Required WITHIN Time Period
States: Florida, Tennessee, Idaho
Requirement: Must establish supervision within specified timeframe after license approval
Process: Apply for license β Find supervisor β Begin practice
π― State-Specific Supervision Requirements
- π΄ Florida: Must agree to written protocol with licensed physician, but can apply first
- π½ Iowa: Must secure employment offer from healthcare provider BEFORE application
- π§ Wisconsin: Must have full-time employment offer from approved facility BEFORE application
- ποΈ Illinois: Employment arrangement required prior to application for limited license
- π΅ Arizona: Must have employment offer from healthcare provider BEFORE application
- π΅ Tennessee: Must practice under collaborative practice agreement (timing flexible)
- ποΈ Idaho: Must secure employment at facility with accredited residency program
π₯ Types of Supervising Physicians Required
π ABMS Recommendations (Becoming Standard)
Supervisor Qualifications: Board-certified physician of the SAME specialty as the IMG plans to practice, with experience in medical education and assessment.
π Supervision Intensity Levels
- Direct Physical Supervision: Florida GAPs - supervisor must be physically present
- On-Site Supervision: Initial periods requiring same-location practice
- Collaborative Practice: Tennessee, Missouri-style agreements with defined responsibilities
- Progressive Independence: Gradually increasing autonomy based on competency assessments
π Strategies for Finding Employment and Supervision
π₯ Healthcare Facilities Most Likely to Hire IMGs
- Federally Qualified Health Centers (FQHCs)
- Community Health Centers
- Rural hospitals and clinics
- Academic medical centers
- Safety net hospitals
- Indian Health Service facilities
π― Networking and Application Strategies
- State medical societies
- IMG professional organizations
- Healthcare job boards
- Direct facility outreach
- Medical conferences and events
- Alumni networks
π What Employers Look For in IMG Candidates
- ECFMG Certification: Non-negotiable requirement for most positions
- English Proficiency: Strong communication skills essential
- Specialty Experience: Documented practice in relevant specialty
- Cultural Adaptability: Understanding of U.S. healthcare system
- Licensing Progress: Evidence of working toward state licensure
- References: Professional recommendations from previous practice
β° Recommended Timeline for IMGs
- 6-12 Months Before: Begin ECFMG certification process
- 3-6 Months Before: Start networking and job searching in target states
- 2-3 Months Before: Submit applications to healthcare facilities
- 1 Month Before: Secure job offer and prepare license application
- Application: Submit state license application with employment documentation
Pro Tip: For states requiring employment before application, start job searching 3-6 months early. Many healthcare facilities in underserved areas are actively seeking qualified IMGs and may assist with the licensing process.
π‘ State-Specific Job Search Tips
- Arizona: Focus on counties with <1M population - check county websites for healthcare needs
- Iowa: Target rural and underserved areas - Iowa has strong FQHC network
- Wisconsin: Look for positions at FQHCs, hospitals, community health centers
- Illinois: Focus on areas with unmet medical needs - many opportunities in Chicago suburbs and rural areas
- Florida: While job offer not required before application, having one speeds the process significantly
π IMG Provisional vs. Assistant Physician Programs
π IMG Provisional License Programs
Target Audience: Experienced international physicians
Requirements:
- 3-5+ years international practice
- ECFMG certification
- Unrestricted foreign license
- Completed international residency
Goal: Utilize experienced physicians to address shortages
π Assistant Physician Programs
Target Audience: Recent medical graduates (mostly U.S.)
Requirements:
- Recent graduation (1-3 years)
- USMLE Steps 1 & 2
- No residency completion
- Often state residency required
Goal: Bridge to residency or alternative pathway
π― States Specifically Targeting IMGs (Not Recent Graduates)
- Florida: Requires 4+ years active international practice
- Iowa: Requires 5+ years post-residency practice
- Wisconsin: Requires 5+ years licensed practice in home country
- Virginia: Requires 5+ years foreign practice experience
- Tennessee: Focuses on internationally trained physicians
- Idaho: Requires 3+ year international residency completion
Key Distinction: IMG provisional programs specifically value international experience and training, while Assistant Physician programs primarily serve as temporary measures for recent graduates seeking residency positions.
π Advantages of IMG Programs for International Graduates
- Recognition of Experience: Years of international practice count toward eligibility
- Faster Integration: Designed for practicing physicians, not students
- Specialty Recognition: International specialty training often accepted
- Permanent Pathways: Clear routes to full, unrestricted licensure
π Program Comparison: IMG vs. Assistant Physician Pathways
π IMG Provisional License Programs
Target: Internationally trained physicians with practice experience
Requirements: 3-5 years international practice, ECFMG certification
Focus: Addressing physician shortages with experienced doctors
Examples: Florida, Tennessee, Idaho, Wisconsin
π Assistant/Associate Physician Programs
Target: Recent medical graduates (typically U.S.) without residency
Requirements: USMLE Steps 1 & 2, recent graduation
Focus: Bridge to residency or alternative practice pathway
Examples: Missouri, Utah, Kansas, Arkansas
π Evolution Toward Full Licensure Pathways
- Missouri (Proposed): 5 years AP practice β full licensure without residency
- Idaho (Proposed): 36 months practice + USMLE Step 3 β automatic conversion
- Arkansas: 2 years academic license β full licensure
- Utah: Reformed to remove geographic and specialty restrictions
π Key Trends in Assistant Physician Programs
- Expansion of Eligibility: Longer application windows, broader criteria
- Reduced Restrictions: Fewer geographic and specialty limitations
- Pathways to Full Licensure: Conversion mechanisms without residency requirement
- Increased Supervision Capacity: More APs per supervising physician
- Enhanced Scope: Expanded prescriptive authority and practice settings
Convergence Trend: Both IMG and Assistant Physician programs are evolving toward similar goals - creating alternative pathways to full medical licensure that bypass traditional U.S. residency requirements while maintaining quality and safety standards.
π Board Certification & Professional Standards
Important Distinction: Medical licensure vs. Board certification - Understanding the difference and pathway to full professional recognition.
Medical License vs. Board Certification
π Medical License
- Legal requirement to practice medicine
- Reflects minimum standards to diagnose and treat patients
- Does NOT reflect competence in a medical/surgical specialty
- Varies by state requirements
π Board Certification
- Voluntary process building on minimum licensure requirements
- Sets national standards for specialty practice
- Highly valued by employers and patients as quality hallmark
- Required for most employment and payment decisions
π€οΈ ABMS Recommendations for IMG Certification Pathways
- Initial Assessment: Rigorous evaluation of knowledge and skills by independent organization
- Supervised Practice: Progressive assessment by board-certified physicians with medical education expertise
- Gap Training: Access to training addressing identified knowledge/skill gaps
- Final Assessment: Comprehensive evaluation by independent organization before full licensure
β¨ Benefits and Opportunities
β‘ Faster Entry
Bypass 3-7 year U.S. residency programs and enter practice more quickly
π Global Experience Recognition
International medical training and experience finally recognized and valued
π₯ Address Shortages
Help solve critical physician shortages, especially in rural and underserved areas
π° Reduced Competition
Avoid highly competitive residency match process with limited positions
π Career Progression
Clear pathway from provisional to full licensure with supervised practice
π― Targeted Placement
Opportunities specifically in areas with greatest need for physicians
π©Ί Assistant/Associate Physician Programs - Detailed Overview
Pioneer Programs: Several states have established comprehensive Assistant/Associate Physician programs with proven track records, offering alternative pathways for medical graduates.
ποΈ Missouri - The Pioneer (2014)
π Missouri Assistant Physician Requirements
- Residency: Missouri resident and U.S. citizen or legal resident alien
- Education: USMLE Steps 1 and 2 completion within previous 3 years
- Practice Scope: Primary care services in medically underserved areas only
- Supervision: Collaborative Practice Agreement (CPA) within 6 months of licensure
π Missouri Supervision Requirements
- Chart Review: 10% of charts every month (maximum requirement)
- Controlled Substances: 20% chart review when prescribing controlled substances
- Training Period: 1 month continuous work together before practicing at different locations
- On-site Practice: 120 hours over 4 months before off-site controlled substance prescribing
- Capacity: One physician can supervise up to 6 Assistant Physicians
π Missouri's Pathway to Full Licensure (Proposed HB 1010, 2025)
Revolutionary Development: Missouri is considering allowing Assistant Physicians to become fully licensed without residency if they complete:
- 60 months (5 years) of collaborative practice as AP
- USMLE Step 3 passage
- 240 hours postgraduate training (120 core + 120 elective categories)
- 100 CME hours biennially
- Letters of recommendation from supervising physicians
ποΈ Utah & Other Established Programs
Utah Associate Physician Program (2017)
π Utah Requirements
Education: LCME-accredited medical schools (U.S./Canada)
Exams: USMLE Steps 1 & 2 within 2 years of application, 3 years of graduation
Scope: Originally limited to primary care in underserved areas
π 2022 Utah Reforms (HB 400)
Expanded Scope: Removed primary care limitation and underserved area restriction
Reduced Burden: Eliminated chart review requirements and on-site mandates
License Duration: 6-year maximum total licensure period
Other Notable Programs
π΄ Florida Graduate Assistant Physician (2024)
- Duration: 2 years + possible 1-year renewal
- Supervision: Direct, physical supervision required
- Capacity: Supervising physician limited to 2 GAPs maximum
- Liability: Supervising physician liable for GAP's acts/omissions
π΅ Tennessee Graduate Physician (2025)
- Unique Feature: May receive residency credit for CPA completion
- Duration: 2 years, non-renewable
- Location: Medically underserved areas only
- Controlled Substances: Limited prescriptive authority
πΎ Kansas & Arkansas - Unique Approaches
π» Kansas Special Permit (2015)
Eligibility: University of Kansas School of Medicine graduates only
Duration: 1 year maximum, non-renewable
Prescribing: Can prescribe drugs but NOT controlled substances
Expiration: Ends when joining residency program or after 1 year
ποΈ Arkansas Graduate Registered Physician (2015)
Eligibility: Arkansas medical school graduates, Arkansas residents
Practice: Under physician-drafted protocol approved by Board
Status: Dependent medical practitioners
Unique: From 2024, full licensure after 2 years under academic license
π Recent Developments in Existing Programs
π Idaho Bridge Year Physician Evolution
- Current (H 153, 2023): 1-year, non-renewable for recent graduates
- Proposed (H 77, 2025): Rename to "Assistant Physicians"
- Expansion: 3-year eligibility window, renewable licenses
- Pathway to Full Licensure: Automatic conversion after USMLE Step 3 + 36 months practice
π₯ Maryland Supervised Medical Graduate (2024)
- No License Required: Can perform delegated duties under direct supervision
- Duration: Maximum 2 years
- Setting: Same medical office as supervising physician
- Requirements: USMLE Steps 1 & 2, Board-adopted rules
Key Insight: These established programs show evolution from restrictive, temporary licenses toward more flexible pathways with potential for full licensure conversion.
β οΈ Challenges and Considerations
π₯ Practice Limitations
- Initial practice limited to specific healthcare settings
- Geographic restrictions (rural/underserved areas)
- Supervision requirements during provisional period
π Administrative Complexity
- Varying requirements across different states
- New regulations still being developed and implemented
- Credential verification can be time-consuming
β³ Time Requirements
- 2-4 year supervision periods before full licensure
- Ongoing education and assessment requirements
- ECFMG Pathway completion can take several months
Important: Each state's regulations are still evolving. Some programs launched in January 2025 are still developing detailed implementation rules.
π Next Steps for IMGs
π Immediate Actions (2025)
- Research Target States: Compare requirements and opportunities in different states
- Start ECFMG Process: Begin ECFMG certification if not already completed
- Prepare Documentation: Gather all required credentials and verifications
- USMLE Preparation: Ensure Steps 1 and 2 CK are passed
- English Proficiency: Take OET Medicine exam for ECFMG Pathways
π Documentation Checklist
- Medical school transcripts and diploma
- Residency training certificates from home country
- Medical license and practice verification from home country
- USMLE score reports
- Immigration status documentation
- Letters of recommendation
- Professional liability insurance
Professional Tip: Consider working with medical licensing consultants who specialize in IMG licensure to navigate the complex requirements efficiently.
π Key Resources and Contacts
ποΈ ECFMG
Website: ecfmg.org
Services: Certification, Pathways, Credential Verification
π FSMB
Website: fsmb.org
Services: Federation of State Medical Boards, Licensing Guidelines
π USMLE
Website: usmle.org
Services: Examination Registration, Score Reports
π WFME
Website: wfme.org
Services: Medical School Accreditation Standards
π Additional Resources
- State Medical Boards: Contact individual state boards for specific requirements
- Professional Organizations: AMA, state medical societies
- IMG Support Groups: Online communities and professional networks
- Legal Consultation: Immigration attorneys specializing in medical professionals
π― Conclusion
β Key Takeaways
- Revolutionary change in U.S. medical licensing for IMGs
- 13+ states now offer pathways without U.S. residency
- Opportunities primarily in underserved and rural areas
- ECFMG certification and USMLE completion remain essential
- Supervision periods lead to full licensure
π The Future is Now
This represents the most significant change in IMG licensing in decades. For qualified international physicians, the opportunity to practice in the United States without completing a U.S. residency is finally a reality.
Β© 2025 β’ Information compiled from official state medical board sources and ECFMG guidelines β’ Always verify current requirements with relevant authorities